Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder-Other-Vertigo
Treatment: Inpatient hospital stay
The health plan denied the inpatient stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

This is the case of a patient admitted to the hospital for the diagnosis of Vertigo. The patient presented with symptoms of dizziness starting when she woke up from sleep the morning of admission. Vital signs demonstrated a temperature of 98 Fahrenheit, pulse 75, respiratory rate 20, blood pressure 132/ 86 and oxygen saturation of 98% on room air. Physical examination showed no acute distress or altered mental status. Neurological exam demonstrated cranial nerves 2 through 12 grossly intact. Troponin was negative and glucose was 145. The complete blood count was normal, and a D dimer (a protein fragment from the breakdown of a blood clot) was negative. Coagulation times were normal. A computed tomography (CT) scan of the head found no acute infarct or hemorrhage. Chest x-ray found no acute pulmonary pathology. Neurology evaluated the patient and recommended aspirin and a statin. Additional testing recommended included an echocardiogram and magnetic resonance imaging (MRI) of the brain. A CT angiogram of the head and carotids performed was unremarkable. The patient ultimately was felt to have benign paroxysmal postural vertigo (BPPV) and after clinical improvement was able to be discharged with a plan for an outpatient MRI.

Medical necessity of an inpatient admission has not been established.

The patient's dizziness ultimately was felt to be a result of BPPV and would have likely resolved without interventions, but regardless the patient did not have stroke, transient ischemic attack (TIA), dissection, hemorrhage, ischemia, or other malignant etiology causing her symptoms.

According to the Milliman Care Guidelines (MCG) Health Dizziness 24th edition and the documentation submitted, the patient did not have acute bacterial labyrinthitis, cerebellar, brainstem or cerebral ischemia or hemorrhage, dissection, hemodynamic instability, persistent symptoms beyond observation care, persistent vomiting, arrhythmia, or new neurological findings requiring inpatient care. The patient did not have monitoring needs requiring inpatient care such as intracranial pressure monitoring.

Also, according to Up-to-Date, 2021:

"While the natural history of BPPV is not well studied, it is widely accepted that untreated episodes usually resolve spontaneously over days to weeks, sometimes longer. In a case series of 108 patients with BPPV who did not receive canalith repositioning maneuvers, positional vertigo symptoms disappeared at a mean of 39 days for patients with posterior BPPV and a mean of 16 days for those with horizontal BPPV. Patients with BPPV due to certain etiologies such as ischemia, vestibular neuronitis, or trauma may have a more prolonged course than those with idiopathic BPPV ."

Although the patient had needs best addressed in the hospital setting the monitoring, diagnostic workup and therapeutic interventions prescribed could have been safely administered at a lower level of care. Therefore, medical necessity of an inpatient admission has not been established.