Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient stay. 
The denial is upheld. 

The patient is a female who presented to the hospital with intermittent right thigh pain and headache, described as 10 out of 10 throbbing pain, with associated eye-watering swelling and redness. Symptoms have been present for about two weeks, worsening towards the end of the day and exacerbated by noise and light. 
Vital signs showed a pulse rate of 98, blood pressure 112/80, and normal temperature and respirations. body mass index (BMI) is 21. 
On exam, the patient is normocephalic and atraumatic. Anterior neck fullness was detected, with a goiter and a bruit auscultated over the thyroid. There was no evidence of tremor, and strength was preserved on the neurologic exam. 
Laboratory studies are fairly unremarkable, including complete blood count (CBC), chemistry panel, and liver enzymes. 
The patient had been originally assessed in the ophthalmology clinic the previous day, for the same symptoms, with recommendations, for brain magnetic resonance imaging (MRI) and lumbar puncture; however, due to childcare issues, she did not come to the hospital until the next day. Ophthalmology diagnosed right eye anterior uveitis, with recommendations for neurology consultation, check autoimmune markers, brain MRI to rule out optic neuritis or pseudotumor cerebri, followed by lumbar puncture. Prednisone drops were given. The medical team also involved endocrinology and ordered the thyroid ultrasound and thyroid function tests. 
The lumbar puncture was performed, showing an opening pressure of 12 and clear cerebrospinal fluid (CSF) fluid removal. Brain MRI was fairly unremarkable. The blurry vision continued; however, the headaches improved on this day, and vital signs were stable. Repeat labs show similar findings to the day before. In addition, a cervical MRI was performed that showed a disc osteophyte at cervical (C)6-7, causing mild spinal stenosis. 
Regarding the goiter, the medical team notes this was biopsied previously with nondiagnostic pathology. The thyroid ultrasound and thyroid function test report were not yet available. 
The patient complained of some back pain at the site of the lumbar puncture complaint of blurry vision. Vital signs remained stable. The thyroid function tests appear normal, and the autoimmune panel was negative, with several additional tests still pending. The neurology team recommends outpatient follow-up. 
The patient was deemed stable for release from the hospital, with appropriate outpatient follow-up with ophthalmology and neurology. 
The subject under review is the medical necessity for the inpatient stay. 

Based on the provided documentation, the patient has been experiencing blurry vision and headaches for two weeks and was noted to have redness, and anterior uveitis per ophthalmology, with questionable papilledema. She was admitted to the hospital for brain imaging to rule out pseudotumor cerebri or a demyelinating disorder. Head computed tomography (CT), brain MRI, and lumbar puncture were all within normal limits, obtained within 24 hours of admission.  The patient had no other focal neurologic deficits. Inpatient hospitalization was not medically necessary based on this documentation.