Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypoglycemia, possible cystitis, and left adnexal cyst.
Treatment: Inpatient hospital admission.
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld. 

This is a female patient who presented to the Emergency Department (ED) with complaints of dizziness and weakness after discontinuing the use of Keppra. The patient's medical history included hypertension as well as seizure disorders. The patient's primary care physician (PCP) wanted her to be seen due to ongoing symptoms and hypoglycemia (twice). The patient's treating physician detailed he spoke with the patient's PCP who also indicated that the patient has lost 7 pounds over the last month and noted some leg swelling. The documentation also indicates that the patient was admitted 2 months prior for a seizure and a magnetic resonance imaging (MRI) that revealed a cyst on the pituitary gland. The patient's physical examination revealed that she was in no acute distress. Her range of movement was normal, and she had full, 5 out of 5, strength. The patient's sensation was also normal, and she was able to ambulate without difficulty. The recommendation was made for laboratory and diagnostic studies.  

The patient's laboratory studies did not reveal any significant abnormalities. The patient's venous partial pressure of oxygen (PO2) was 40 and venous oxygen (O2) saturation was 75. Her troponin was negative and there was a large amount of leukocyte esterase noted in her urine. The patient underwent a chest X-ray that showed no evidence of active disease. The patient's computed tomography (CT) scan of the head revealed no mass, no acute hemorrhage, and no evidence of acute infarct. The patient's CT scan of the abdomen and pelvis revealed an asymmetric urinary bladder wall thickening that may be related to incomplete distention. Clinical correlation was recommended for the possibility of cystitis. There was a 3.4 centimeter (cm) left adnexal cyst which was prominent for the patient's age. The physician indicated the patient should be admitted for further work-up. The patient was being managed for hypoglycemia. The patient was receiving intravenous (IV) fluids. The documentation does indicate that the patient did not have any further significant adverse events while hospitalized and it is noted she signed out against medical advice (AMA) on day 3 of admission.

According to current literature, a patient may be admitted to inpatient services when there is documentation detailing a neurologic finding that requires inpatient care, altered mental status that is severe persistent, neurologic trauma, persistent recurrent hypoglycemia despite observation care treatment, or other significant clinical signs or symptoms that do not resolve with observation care treatment. The submitted documentation indicated this patient presented to the ED with complaints of dizziness and weakness after discontinuing Keppra. Additionally, the patient's PCP recommended she be seen for further evaluation due to hypoglycemic episodes. However, the patient's physical examination in the ED did not reveal any significant findings warranting inpatient services. Furthermore, there were no laboratory or diagnostic findings that warranted the need for the patient to be admitted as an inpatient versus work-up as observation. Thus, the inpatient hospital admission was not medically necessary for this patient.

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital admission should be upheld. The medical necessity is not substantiated.