Appeal type: Medical necessity
Decision: Upheld

Neurology, Headache
Inpatient hospital stay

The patient has a past medical history of hypertension and diabetes mellitus who presented with progressively worsening bilateral occipital headache for 4 days associated with neck stiffness and pain. The patient tried Vicks vapor rub for relief with no alleviation of symptoms. The patient bumped the back of his head while getting into the car on the way to the hospital. The emergency department (ED) physician noted that the patient did not typically suffer from headaches and appeared uncomfortable with tenderness to the left cervical paraspinal muscles. The patient was also noted to have neck stiffness however the patient had no focal deficits. During the initial examination in the emergency room, the patient had a lower right occipital hematoma with tenderness, neck stiffness, and tenderness over bilateral trapezius muscles at the base of the skull. The ED physician initially thought the patient may have a migraine versus tension headache versus muscle tension. In the emergency room, the patient received Reglan, Benadryl, Tylenol, and Robaxin. The patient stated improvement with symptoms after receiving Robaxin in the ED. The patient was given a dose of ceftriaxone and vancomycin to cover meningitis, given the neck pain. Neurosurgery was consulted and recommended computed tomography angiography (CTA) of the head as well as a neurology consultation. The computed tomography angiography (CTA) head was unremarkable. Neurology was consulted and recommended a repeat CT head without contrast and if negative, would perform a lumbar puncture (LP) to rule out subarachnoid hemorrhage (SAH). The repeat CT head showed no acute intracranial abnormality and the patient refused a lumbar puncture and blood work while in the ED. LP  later performed was unremarkable for infection. The patient was admitted to an inpatient level of care for further management of an intractable headache secondary to a possible subarachnoid hemorrhage versus meningitis per the treating physician's clinical impression. The patient was cleared from having meningitis and an intracranial hemorrhage. Subsequently the patient received symptomatic relief with muscle relaxants. The patient was given Robaxin per Neurology recommendations and was changed to baclofen and gabapentin as well as topical menthol and heating pads. The health plan's determination of medical necessity is upheld in whole.
This patient did not fail outpatient treatment since only used Vicks Vapor Rub to try to alleviate the headache and associated symptoms. Moreover, the patient's inpatient stay did not fulfill the inpatient criteria of the Milliman Care Guidelines (MCG) guidelines of "suspected or viral meningitis", "headache", and "neurology". The patient had none of the following: focal neurologic deficits, nausea/vomiting, severe dehydration, bacterial meningitis, SAH, cerebral bleed/edema, or encephalitis. . Despite Neurology and ID noting in their assessments that this patient likely did not have a CNS infection and most probably had a cervicogenic headache with cervical muscle spasms, they recommended an LP which was essentially unremarkable- meningitis and subarachnoid hemorrhage were ruled out. Furthermore, the patient noted improvement of symptoms in the ED after receiving Robaxin- a muscle relaxant. Ultimately, this patient's treatment was switched by Neurology from Robaxin to baclofen, Neurontin, heating pads, and topical menthol. The patient could have been treated at a lower level of care rather than as an inpatient admission. The episodic hypertension was likely due to pain from the initial headache and not receiving home clonidine at the proper time during the hospital stay, which also can contribute to a headache and rebound hypertension. Moreover, it is difficult to distinguish cervicogenic headaches from a tension type headache (TTH) vs a migraine, which can often be managed with over the counter medications at an observation level of care or with outpatient treatment. As stated in UpToDate, "Limited evidence suggests that the presence of a combination of physical measures such as palpably painful upper cervical joints, restricted range of neck extension, and muscle impairment characterized by reduced electromyographic activity in the deep neck flexors can distinguish cervicogenic headache from migraine and tension-type headache." , "Reasonable choices for acute TTH include a single dose of ibuprofen (200 or 400 mg), which may have fewer side effects than other nonsteroidal anti-inflammatory drugs (NSAIDs), naproxen sodium (220 or 550 mg), or aspirin (650 to 1000 mg). Ketoprofen 25 or 50 mg is effective, but this product is no longer generally available over-the-counter. For those failing the better proven options, diclofenac (25 to 100 mg) is a potential alternative. For patients who cannot tolerate nonsteroidal anti-inflammatory drugs (NSAIDs) or aspirin, a single dose of acetaminophen (paracetamol) 1000 mg can be used instead." The patient had not attempted these over-the-counter (OTC) interventions prior to coming to the ED. Finally, there were no red flag indications of the patient's condition, especially based on the assessments of the specialty consults which consistently noted that the patient likely did not have a cerebral bleed or CNS infection.