Appeal type: Medical necessity
Decision: Overturned



Diagnosis: Idiopathic left optic neuritis.
Treatment: Inpatient Hospital Admission.
The insurer denied the inpatient hospital admission.
The health plan's determination is overturned.

The patient is a male who initially presented to the emergency department with concerns about right-sided blurry vision changes and head pressure. His pertinent history included idiopathic optic neuritis in the left eye with residual blurry vision. The initial vital signs revealed a temperature of 98.2, heart rate (HR) of 82, blood pressure (BP) of 139/90, respiratory rate (RR) of 20, and peripheral capillary oxygen saturation (SpO2) was 96 percent (%) on room air. The initial examination documented the patient as alert and oriented with the inability to count fingers in bilateral lower visual fields, but no other neurologic deficits. The initial laboratory testing revealed a white blood cell count (WBC) of 9.6, hemoglobin of 16.0, platelets (Plt) of 332, sodium 141, potassium of 5.0, blood urea nitrogen (BUN) 16.0, creatinine 1.21 and his glucose was 88.
The electrocardiogram (EKG) was unremarkable. The computed tomography (CT) of the head was unremarkable. The computed tomography angiography (CTA) of the brain and neck was relatively unremarkable. Ophthalmology had an impression of papilledema versus optic neuritis. Recommendations included emergent magnetic resonance (MR) of the head and orbit imaging as well as additional laboratory testing. Neurology was consulted and noted visible papilledema or right optic nerve with visual deficits. The magnetic resonance venography (MRV) of the head was relatively unremarkable. The magnetic resonance imaging (MRI) of the orbits with and without contrast was performed which revealed mild enhancement in the distal intraorbital portion of the right optic nerve. High-dose intravenous Methylprednisolone was initiated for a planned 3 days. The patient was discharged with plans to return to the emergency department for continued intravenous steroids.

Based on the clinical documentation provided, evidence-based literature, and standards of care, an acute inpatient level of care was indicated as medically necessary for the entire admission. Bennett notes optic neuritis, or inflammation of the optic nerves, is a frequent cause of acute optic nerve injury in children and adults. While optic neuritis is frequently associated with multiple sclerosis (MS), the causes of optic neuritis are protean. As a result, the prognosis and treatment of optic neuritis will vary depending upon the etiology, duration, and severity of vision loss, prior injury, and the success of prior treatment. Optimal care of patients with optic neuritis, therefore, depends on rapid recognition, appropriate diagnostic studies, and early institution of effective therapies.[1]
The patient had a history of idiopathic left optic neuritis and presented with acute right-sided blurry vision and head pressure. The initial examination documented right vision field deficits. The initial stroke evaluation including a CT of the head and CTA of the brain and neck were relatively unremarkable. Neurology was consulted and documented visible papilledema or right optic nerve. The MR of the orbits revealed mild enhancement in the distal intraorbital portion of the right optic nerve. The treatment plan included high-dose intravenous corticosteroids for three days followed by a taper.
Clinical indications for admission to inpatient care were met. The patient had a neurologic finding requiring inpatient care evident by new onset visual field loss with a neurologic assessment concerning for papilledema. Inpatient treatment of high-dose intravenous corticosteroids was pursued.[2]

The health plan's determination of medical necessity is overturned in a whole.