Appeal type: Medical necessity
Decision: Upheld

Diagnosis: fall with head- strike and loss of consciousness

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld.

The patient is an adult with a history of deep vein thrombosis (DVT), pulmonary embolism (PE), seizure, aneurysm, congestive heart failure (CHF), cerebrovascular accident (CVA), bipolar disorder, post-traumatic stress disorder (PTSD), depression, factor V Leiden mutation, who presented to the Emergency Department (ED) for an emergency evaluation due to fall with head- strike and loss of consciousness. The patient endorses feeling tired while outside, walked in and barely made it to their room where they felt dizzy ("room spinning") and lost consciousness. Per others there, the patient was told they were out for about 5-10 minutes, hit their head on the bed rail, and fell on their right side. The patient endorses multiple other episodes of similar. Of note the patient was recently in the hospital and another hospital where they are from. On initial presentation, the patient was afebrile (temperature of 99.3 degrees Fahrenheit), with hypertension (Blood Pressure 173/104). On examination, the patient appeared to have abdominal tenderness with an umbilical hernia and a laceration present. Laboratory studies were remarkable for anemia - hemoglobin 10.8, thrombocytopenia - platelets 173, acidosis, elevated lactate to 2.5, hyperglycemia - 250. Computed tomography (CT) head demonstrated encephalomalacia. CT of the thoracolumbar spine demonstrated:
1) Levoscoliosis of the lumbar spine with a Cobb angle of approximately 18 degrees. There is also chronic increased thoracic kyphosis. 
2) Multilevel degenerative osteoarthritic changes that are most pronounced involving the lower lumbar facet joints.
3) No evidence of acute fracture of the thoracic spine or the lumbar spine. The patient was admitted for further workup and management. 

This adult patient with an extensive past medical and surgical history as detailed above and below was brought in by ambulance after a witnessed fall at the shelter. The patient was said to have felt lightheaded after getting out of bed then fell back and hit their head on the bed railing. Per witnesses according to emergency medical services (EMS), the patient hit their head hard on the bed frame and lost consciousness for a few minutes, no seizure activity, tongue biting, fecal or urinary incontinence. The patient has a history of DVT / PE on Eliquis. Per patient, they had 2 stents placed 3 weeks ago and moved to a different state 4 days ago. The patient endorsed a history of seizures and episodes of loss of consciousness (LOC) in the past.

The physical exam on admission was benign: Blood Pressure 173/104 patient was afebrile.
The ED work up included a Chest X ray, Pelvis X ray, CT of the head without contrast, CT of the C spine and CT of the Lumbar spine showing evidence of arthritis. 

Later that day, the patient was stable, alert and oriented.  Serum lactate was 2.5 and serum Amylase was 43.

In this case, this is a patient with multiple medical problems including a seizure disorder who experienced a brief episode of syncope and then woke up. The patient underwent a battery of testing in the ED which was generally negative. The patient in the emergency room remained stable throughout the stay. The patient's blood pressure was elevated.  Because of the fall a CT of the head, C spine and pelvis was ordered which only demonstrated chronic arthritis. The patient is a known epileptic. Cardiac etiologies were ruled out as well.

While in the ED the patient had a complete set of blood test to rule out sepsis, and cardiac etiologies. 

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 the inpatient is not substantiated.