Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Headache

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is modified. 

This female patient has no significant medical history.

This case involves a patient who presented to the emergency department complaining of a 2-month long headache with associated symptoms of diarrhea as well as lightheadedness.  She indicated she did eat spicy popcorn the day prior.  The physical examination revealed oxygen saturation 100% (percent) with a blood pressure of 100/60.  The abdominal examination revealed no tenderness as well as no guarding and no rebound.  The physician indicated it was likely gastritis and it was recommended she receive a GI (gastroenterology) cocktail.  The physician indicated upon further examination she was uncooperative.  It was recommended she undergo laboratory diagnostic studies.  She was recommended to undergo an oral trial.  She tolerated oral intake however complained of dizziness when she stood up.  She endorsed a headache and stated the room was spinning.  The documentation indicated she was given meclizine and Tylenol.  The laboratory studies did reveal a white blood cell count of 11.7.  The recommendation was made for a neurology consultation.  A computed tomography (CT) scan did reveal a Chiari malformation.  It was recommended she undergo a magnetic resonance image (MRI).  The patient was admitted for intractable dizziness likely secondary to Chiari malformation versus minor hydrocephalus.  The documentation does indicate an MRI showed complete agenesis of the corpus callosum and no evidence of Chiari malformation.  She was recommended for further services that include physical therapy.  The patient continued with medications that included meclizine.  She continued with treatment and was noted to have improvement.  She was able to walk without dizziness and was deemed clinically stable for discharge.

According to current literature, a patient may be admitted to inpatient services when there is evidence of hemodynamic instability that is not readily correctable at a lower level of care, vomiting that is severe or persistent, cardiac arrhythmia of immediate concern, severe new neurologic findings, or signs or symptoms that are severe and persistent such as the inability to ambulate.  The submitted documentation indicated the patient was seen in the emergency department, where it was noted she continued to complain of intractable dizziness.  The documentation indicated she underwent multiple laboratory diagnostic studies revealing a white blood cell count of 11.7 with a CT scan showing the possibility of a Chiari malformation.  The patient was admitted for further treatment and continued to improve throughout the stay.  The documentation indicated she received treatment that included medications with improvement.  While an initial admission may be appropriate given the presenting symptoms and diagnostic findings, the entirety of the stay was not needed.  Note that the neurosurgery consult after review of the clinical scenario and relevant imaging indicated that the findings regarding the corpus callosum was an incidental finding and no neurosurgical intervention was needed.  A progress note indicates feeling better, but dizziness not completely gone.  Able to eat breakfast with no vomiting.  Ambulated with slow broad based gait.  Plan was further care at home.  As such, in view of the presentation and the possible acute findings on initial evaluation the admission and subsequent treatment allow admission.  However, as noted above, as of a few days prior to discharge, issues were resolved, patient clinically improved and thus the patient could have been discharged at an earlier time.  The request is partially overturned.

The health plan did not, in part, act reasonably, with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital admission is modified.  The medical necessity is partially substantiated.