Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness
Treatment: Inpatient admission
The insurer denied coverage for Inpatient admission.
The denial is Upheld.  

The adult patient presented to the hospital with history of asthma, chronic migraines, fibromyalgia, obstructive sleep apnea on continuous positive airway pressure (CPAP), and gastroesophageal reflux disease (GERD). The patient presented with dizziness; the patient denied head trauma. The dizziness worsened with changing head direction. The symptoms started the previous day. The patient had not had similar episodes before. The patient denied weakness, numbness, shortness of breath, chest pain, palpitations, headache, hearing loss, ear ringing, blurred vision, sweating, nausea, vomiting, and trauma. There was no history of seizure or syncope. The patient's review of systems was positive for diarrhea and dizziness. Vital signs noted blood pressure of 129/69, temperature 36.6 (degrees) Celsius, pulse 76, respirations 18, and oxygen saturation 100% (percent) on room air. The patient rated their pain 6 out of 10. The physical exam findings of the patient noted normal range of motion (ROM). There was horizontal nystagmus and corrective saccades on HiNTs exam. The electrocardiogram (EKG) showed accelerated junctional rhythm, left axis deviation, incomplete left bundle branch block, moderate voltage criteria for left ventricular hypertrophy which could be normal variant, T wave abnormality with consideration for anterior ischemia, and prolonged QT. Prior electrocardiogram noted incomplete left bundle branch block (BBB) and T wave abnormality with consideration for anterolateral ischemia. Given the patient's history, the findings were likely benign paroxysmal positional vertigo or other peripheral course. There was a plan to assess for metabolic or cardiac abnormalities given that the patient had widespread T wave inversion. Given that this was first-time presentation of vertigo, the provider also planned to assess for intracranial pathology. Computed tomography of the head was negative for acute pathology. The patient was admitted to the hospital for persistent dizziness that required magnetic resonance imaging (MRI) to rule out post-cerebrovascular accident (CVA).  Laboratory results were unremarkable with no severe electrolyte derangements. CT (Computed tomography) angiogram of the head and neck noted no acute findings in the arteries. The patient was evaluated by Neurology and recommended for Ear, Nose & Throat (ENT) follow-up due to hearing loss. The patient was prescribed Meclizine. MRI showed incidental empty sella syndrome. The patient remained clinically and hemodynamically stable, afebrile, and without leukocytosis. The patient was deemed appropriate for discharge with a plan for outpatient follow-up with ENT and Neurology.

It was argued that the inpatient admission was medically necessary for the patient to address severe and progressive dizziness and lightheadedness associated with nausea. However, the documentation did not identify suspected etiology that required admission such as vertebral artery dissection or acute demyelination. There was no hemodynamic instability that was not corrected by appropriate treatment. There were no severe or persistent symptoms that continued despite observation care.  While there was some concern regarding widespread T wave inversion and there was partial bundle branch block, these findings were not new. The findings were evident on electrocardiogram from 2020. Based on the documentation, the patient's diagnostic work-up, monitoring, and treatment could have been completed at observation level of care.  

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 an inpatient admission is not substantiated.