Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.



The patient has  past medical history significant for Paget's disease of the right hip, depression, and anxiety who presented to the emergency department with complaints of dizziness, a sensation that his head was spinning, and a headache. In addition, it was also mentioned that the patient had an imbalanced gait and tremors, with short-term memory loss.
At the time of the initial evaluation, he described his headache as 2/10 in severity with no modifying factors. The patient denied any abnormal body movements, or bowel or bladder incontinence. He denied syncopal episodes. His review of systems was also positive for malaise and fatigue.
When seen by the admitting physician, he was afebrile. His pulse rate was 98 beats per minute (bpm), respiratory rate 16 breaths/minute, blood pressure 159/85, and oxygen saturation 100% on room air. The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. The neck was supple without lymphadenopathy, masses, jugular vein distention (JVD), and carotid bruits. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. The lungs were clear to auscultation without wheezes, rales, or rhonchi. The abdomen was soft, non-tender to palpation, with normal bowel sounds, without guarding or rebound. The patient was alert and oriented to person, place, and time. He had pressured speech.
Laboratory evaluation revealed that the white blood cell count was 5.4, hemoglobin 13.5, hematocrit 42.0, and platelets 280. The sodium was 140, potassium 3.8, chloride 105, bicarbonate 25, blood urea nitrogen (BUN) 9.7, and creatinine 1.19. Liver function tests were normal.
A computed tomography (CT) angiogram of the head and neck revealed no occlusion of the major intracranial arterial branches. A CT angiogram of the neck was unremarkable. A CT scan of the head without contrast did not show acute abnormalities.
The patient was admitted to the hospital with dizziness. The differential diagnosis included transient ischemic attack (TIA) versus panic attack. It was stated that the patient had an elevated blood pressure but was never formally diagnosed with hypertension. The patient was started on a low dose of amlodipine. He was continued on his home regimen of antihypertensive medications.
In the hospital, the patient was seen by a neurologist who also suggested that the patient's symptoms could represent a TIA versus panic attack. The neurologist recommended cardiac monitoring, carotid duplex, checking additional laboratory studies, and taking an aspirin.
The patient was also seen by a psychiatrist who suggested that the patient had a generalized anxiety disorder but did not need an acute inpatient hospitalization.
During the hospital stay, the patient underwent an echocardiogram, which demonstrated a normal left ventricular ejection fraction with grade 1 diastolic dysfunction. In the hospital, the patient remained in stable clinical condition and was transitioned to outpatient care.
At issue is the medical necessity of an inpatient stay.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
Based on the initial evaluation the patient was suspected to have TIA. According to the nationally accepted standards of care, an acute inpatient level of care is generally indicated in cases of transient ischemic attack associated with hemodynamic instability, and persistent or recurrent focal neurologic signs. Admission at the acute inpatient level of care is also required for patients with TIA associated with altered mental status, cardiac arrhythmias of immediate concern, a clinically significant cardiac disorder such as severe valvular disease, atrial myxoma, cardiomyopathy, cases of severe hypertension which could not be controlled by the emergency department or at the observation level of care, certain cases when patients require inpatient procedure, or surgery such as endarterectomy, also in cases when parenteral anticoagulation or administration of antiplatelet agents is required. 
The review of the medical records clearly demonstrated that in this clinical case that the patient had none of the circumstances listed above. Therefore, neither the severity of the patient's condition nor the complexity of services provided rose to the acute inpatient level of care. At the time of admission, the patient complained of a sensation of spinning. However, there was no evidence that his symptoms were related to acute bacterial labyrinthitis, cerebellar ischemia or hemorrhage, persistent vomiting, or arrhythmias of immediate concern. Taking into consideration this information, the workup and clinical monitoring could have been performed at a lower level of care.
Overall, this patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. The Milliman Care Guidelines (MCG) Health Inpatient & Surgical Care 25th Edition criteria for Dizziness were reviewed. There was no evidence that these criteria were applicable in this clinical case justifying admission at the acute inpatient level of care.