Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Headache.
Treatment: Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

The patient has stage IV lung cancer and recently diagnosed brain metastasis who presented to the hospital with a worsening headache, primarily on the left side of the head. His headache was typically treated with acetaminophen (APAP) but this time it did not help. The associated symptoms included abdominal bloating, discomfort in the upper abdomen with radiation to the back, nausea, and 4 episodes of vomiting. The patient also noted blurred vision, which abated after his headache improved.

On the physical exam, the patient's temperature was 97.2 degrees Fahrenheit (F), heart rate 96 beats per minute (bpm), respiratory rate 16 breaths/minute, blood pressure 108/69, and oxygen saturation 99% on room air.

When the patient was seen by the admitting physician he was awake, alert, and oriented times (x) 3. He was in no acute distress. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. The lungs were clear to auscultation without wheezes, rales, or rhonchi. The abdomen was soft, non-tender to palpation, with normal bowel sounds, without guarding or rebound.

On the neurological exam, the patient had intact cranial nerves. He was awake, alert, and oriented to person, place, and time. The patient had normal muscle strength in the upper and lower extremities with normal sensation bilaterally.

Laboratory evaluation revealed that his white blood cell count was 8.63, hemoglobin 13.5, hematocrit 40.0, and platelets 105. Sodium was 127, potassium 4.1, chloride 99, bicarbonate 23, blood urea nitrogen (BUN) 9, and creatinine 0.7. The liver function testing was within normal limits.

A computed tomography (CT) scan of the head revealed multiple hyperattenuating mass lesions corresponding to known metastatic disease. There was no intracranial hemorrhage or acute territorial infarction.

The patient was admitted to the hospital with complaints of a headache in the setting of brain metastasis with previously diagnosed vasogenic edema and diagnoses of headache, hyperosmolar euvolemic hypernatremia, and metastatic lung cancer.

At the time of admission, the patient already reported resolution of the headache and associated symptoms. The hyponatremia work-up was performed. It was consistent with Syndrome of Inappropriate Antidiuretic Hormone (Secretion) (SIADH), which was attributed to known pulmonary disease and brain metastasis. The patient was recommended 1 liter (L) per day fluid restriction. During the hospital stay the patient underwent serial neurologic exams, which did not reveal any focal findings. The headache never recurred. Reportedly, the patient was educated about "red flag" symptoms and was discharged home with a recommendation to follow up with his oncologist. At issue is the medical necessity of an inpatient stay.

The inpatient hospital stay was not medically necessary for this patient.

The patient presented to the hospital with complaints of headache that was not relieved by APAP. At the same time, in the hospital, these symptoms resolved within a short period of time and never recurred while in the hospital. The patient was afebrile, hemodynamically stable, and had unremarkable results of the neurologic exam.
The laboratory findings were not alarming. The hyponatremia was not unusual in the setting of chronic lung disease and brain metastasis. The hyponatremia was not associated with seizures or neurological signs. During the hospital stay, the patient received treatment with intravenous fluids, antiemetics. A hyponatremia workup was performed. In general, neither the treatments given in the hospital nor the diagnostic studies performed necessitated admission at the acute inpatient level of care.

The hospital stay was relatively short, and there was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care with subsequent transition to outpatient care, rather than admission to an inpatient level of care.

Overall, he remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. Neither the severity of the patient's condition nor the complexity of the services provided rose to the level of acute inpatient level of care.