Appeal type: Medical necessity
Decision: Upheld

Central Nervous System/Neuromuscular Disorder/Other/bleeding in brain.
Inpatient Hospital Admission.
The health plan denied the requested inpatient admission as not medically necessary. 
The health plan's determination is upheld.

The patient is a male with a past medical history significant for benign prostatic hyperplasia (BPH) who presented to the emergency department as a transfer from another facility for evaluation of headache and chest pain. A computed tomography (CT) scan of the head that was performed was concerning for possible right-sided intracranial hemorrhage. The patient was noted to have an elevated blood pressure. When the patient was seen by the admitting physician he denied any symptoms. The patient stated that in the last 5 months that preceded this admission, he had been having chest pain/pressure as well as palpitations at least twice a week. These episodes lasted for approximately 2 hours at a time. The patient blamed those symptoms on stress/anxiety. He also reported quitting marijuana 5 months before his presentation and believed that his symptoms were related to this. The patient stated that he sees his primary care physician yearly but had never been diagnosed with hypertension. He denied fever and chills. The patient denied shortness of breath.
On the physical exam, the patient was afebrile. His heart rate was 65 beats per minute (bpm), with a respiratory rate of 18 breaths/minute, a blood pressure of 124/84 millimeters of mercury (mmHg), and an oxygen saturation of 100% on room air.

The patient was admitted to the hospital with headaches, chest pain, and palpitations. It was mentioned that when he was seen at the first facility he had uncontrolled blood pressures. For evaluation of chest pain/pressure, the patient was ordered 3 sets of cardiac enzymes and an echocardiogram. Rule out of acute coronary syndrome was also suggested. The patient was started on Aspirin, and a cardiology service was consulted. During the hospital stay, the patient underwent a magnetic resonance imaging (MRI) of the brain that demonstrated an 8-millimeter (mm) right parietal periventricular cavernoma with no adjacent edema. There was no evidence of intracranial hemorrhage.
The patient was seen by a cardiology service and according to their recommendation underwent a stress echocardiogram, which was interpreted as a negative study. The cardiac labs were negative, and the patient was cleared for discharge and recommended outpatient follow-up within 2 weeks. During the hospital stay, the patient remained in stable clinical condition and was discharged from the hospital.

I uphold, in whole, the health plan's determination of medical necessity.

Based on the circumstances described, it appears that the patient did not require admission at the acute inpatient level of care for either the headache or chest pain. The absence of severe symptoms or high-risk features, such as sudden onset severe headaches or acute coronary syndromes, suggests that the patient could have been admitted at an alternate level of care for further evaluation and monitoring. The patient's medical records demonstrated no evidence of underlying serious conditions, and therefore, did not warrant admission to the acute inpatient level of care.

Taking into consideration all these facts, I do not see overwhelming evidence that either the severity of the patient's condition or the complexity of services provided rose to the acute inpatient level of care.