Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Head injury 

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
This case involves a teenager under review for inpatient hospitalization. The emergency department (ED) note reported the patient was recently discharged for head trauma with stable contusions. The patient was returning for worsening headaches, ear pain, and dizziness. The patient had been discharged the day prior and was taking oxycodone. The patient stated that headaches had been worse, and medication was not helping with pain. The treatment plan was for labs and a computed tomography (CT) scan. The progress note reported neurosurgery cleared the patient for an outpatient follow-up. It was stated that the patient did not feel comfortable going home given constant severe pain. The patient was admitted to pediatrics for pain control. A determination letter reported the patient presented with dizziness, headache, and was not eating well. It was noted that imaging showed expected findings of resolving head injury. It was noted that the patient was cleared by trauma doctors and neurosurgeons and remained inpatient for headache treatment. The appeal letter reported the patient had a history of acute traumatic subdural hematoma and right temporal bone fracture following an assault. The patient presented to the emergency department with complaints of severe headaches, dizziness, ear pain, and decreased oral intake. The patient was admitted to pediatric services given severe headaches unrelieved by oxycodone and decreased oral intake. The patient reported severe headaches returned every 2-3 hours.

Milliman Care Guidelines (MCG) recommends inpatient admission for headaches when there is severe pain that persists despite observation care, altered mental status that is severe or persistent, vomiting that is severe or persistent, dehydration that is severe or persistent, unruptured but symptomatic aneurysm, dissection, or vascular malformation, venous sinus thrombosis, increased intracranial pressure, cerebral spinal fluid leak, medication-overuse headache that has failed all outpatient management options, vasculitis requiring intravenous corticosteroids, intravenous antithrombotic therapy, or inpatient monitoring, severe (new) neurologic findings requiring inpatient care, new-onset focal neurologic deficit, IV (intravenous) fluid required, and/or increased intracranial pressure or cerebral edema monitoring. 

In this case, the patient presented to the emergency department with complaints of worsening headaches, ear pain, and dizziness. The patient had been recently discharged for head trauma. The patient underwent workup and was cleared by trauma and neurosurgery for outpatient care. The patient was admitted for pain control. However, there was a lack of documentation of significant symptoms that persisted despite observation care. As such, the inpatient hospital admission was not considered medically necessary for this patient.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient hospital admission is not substantiated.