Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Falls; congenital severe communicating hydrocephalus
 
Treatment: Inpatient Admission

The insurer denied coverage for Inpatient Admission. The denial was upheld.

This patient is a female who presented to emergency department.  The patient had a past medical history of congenital severe communicating hydrocephalus, orthostatic hypotension.  The patient had a history of recurrent falls usually without loss of consciousness.  The patient had a temperature 99.2 with a heart rate of 114, respirations 16, oxygen saturation 98% and blood pressure 120/78.  The patient complained of 4/10 pain to lower back and head.  The patient had a Glasgow coma scale score of 15.  The patient had a fall 1 hour prior to admission.  The patient denied any dizziness/lightheadedness prior to fall.  The patient stated that she woke up and was on the floor.  The patient complained of posterior head pain and lower back pain.  Examination showed right-sided temporal contusion.  There was bruising to left lower extremity.  The patient had a white blood cell count of 13, red blood cell count 4.14, hemoglobin 13, hematocrit 29.4, platelets 206.  CT the head revealed stable chronic severe communicate and hydrocephalus.  There was no shift of the midline structures, mass-effect, hemorrhage or other issues.  There was no evidence of acute infarction.  Chest x-ray was negative.  X-ray of the pelvis was negative.  An EEG showed no seizures.  The patient refused physical rehabilitation and was discharged.
The medical literature indicates that inpatient admission is indicated for patients with hemodynamic instability, altered mental status is severe persistent, diagnosis requiring inpatient admission, cardiac disease or finding that indicates necessity of immediate intervention, cardiac ischemia, sustained or symptomatic ventricular tachycardia, symptomatic conduction system disease, bradycardia or sinus pauses, supraventricular tachycardia, atrial fibrillation with rapid ventricular response pacemaker malfunction, inheritable cardiovascular condition predisposing to arrhythmias diagnosed or suspected dehydration that is severe persistent, syncope causing injury requiring hospitalization or continuous intravenous infusion of anticoagulation, platelet inhibitor, vasoactive or antiarrhythmic medication needed.  
The documentation indicated that the patient did have a fall with a loss of consciousness.  There was no postictal state following the fall.  The patient had imaging studies that showed no evidence of significant findings.  A CAT scan showed no shift of midline structures, mass-effect or hemorrhage.  EEG showed no seizures.  There was no evidence of hemodynamic instability, altered mental status that was severe persistent, diagnosis requiring inpatient admission, cardiac ischemia, sustained or symptom medic ventricular tachycardia, symptomatic conduction system disease, bradycardia or sinus pauses, supraventricular tachycardia, atrial fibrillation with rapid ventricular response, pacemaker malfunction, dehydration that was severe persistent or syncope causing injury requiring hospitalization.  Therefore, the patient's condition was appropriate for level of observational care rather than inpatient level care.  As such, the inpatient admission was not medically necessary. 

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