Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Migraine headaches

Treatment: Inpatient admission

The insurer denied coverage for the inpatient admission.

The denial is upheld.

This is a female patient who has a history of meningioma, migraine, and myoclonus. The patient presented to the Emergency Department for persistent headache and myoclonic jerks. The patient reported a blood pressure reading of 190/110 at home which prompted her to present to the Emergency Department. She had recently been admitted to the neurology service and had an extensive work-up that was overall negative. She was discharged on Depakote daily with some improvement in symptoms.  

Recently, she had persistent headaches and myoclonic jerks daily. The patient was admitted to observation with the general neurology service for an extensive work-up regarding episodes of myoclonic jerking, intermittent hypertension, and intermittent flushing. The computed tomography angiography (CTA) of the head and neck revealed no acute intracranial hemorrhage, large territorial infarct, or mass. There was a stable calcified structure near the falx that was likely a meningioma. There was no severe stenosis or occlusion of the major arterial vasculature of the head neck. The computed tomography (CT) of the chest, abdomen, and pelvis revealed a left lower lobe subsegmental pulmonary embolism. The patient underwent an internal medicine consultation and the recommendation was further work-up for hypercoagulable disorder. The patient underwent a lumbar puncture. She was given medications for nausea and pain, and she was also given Depakote. The patient was discharged in fair condition with a diagnosis of migraine headaches.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. Milliman Care Guidelines indicate that an inpatient admission is appropriate for patients with encephalitis, severe Central Nervous System (CNS) infection, vasculitis, such as an altered mental status that is severe persistent or transient alteration in consciousness requiring high risk etiology, a cerebral aneurysm, neurologic findings requiring inpatient care, myasthenia gravis crisis or inpatient monitoring if needed, multiple sclerosis, Parkinson's disease, amyotrophic lateral sclerosis with inpatient needs, severe myopathy, neuropathy, or other neuromuscular disease, complication of congenital alert degenerative disease, suspected or confirmed nerve or muscle toxic injury, and neurologic trauma requiring inpatient treatment or complications of their neurologic device. This patient did not have any of the above indications for admission. The patient was diagnosed with migraine headaches, which could have been treated in observation.  

Additionally, the guidelines indicate that regarding the pulmonary embolus, admission is appropriate for patients who have hypoxemia, vital sign abnormality, chronic cardiopulmonary disease, cardiac arrhythmia of immediate concern, syncope, right ventricular dysfunction and strain, positive cardiac biomarker, or a contraindication to the outpatient use of medication with rapid anticoagulation effects, such as respiratory symptoms are severe, significant bleeding or allergic for autoimmune or coagulopathic reaction in response to anticoagulation, personal or family history of significant allergic, autoimmune, or coagulopathic reaction in response to anticoagulation required monitoring beyond the observation period, for a personal or family history of significant bleeding tendency or bleeding disorder that requires monitoring beyond observation care.  It is understood the patient had a subsegmental pulmonary embolism per the CT of the chest, abdomen, and pelvis. The records did not indicate the patient could not undergo treatment and testing while under observation. 

The medical necessity for the inpatient admission is not substantiated. The insurer's denial is upheld.