Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vision change and headache

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

This case involves a patient who presented to the emergency department complaining of diplopia that began occurring 3 days prior.  The patient denied dizziness, headaches, or head injury.  The patient endorsed a history of hypertension and was taking amlodipine.  The patient reported a new onset of blurred vision.  On examination, the patient's blood pressure was 177/95 with a heart rate of 74, respirations 18, temperature 98.2 degrees, and pulse oximetry at 98% on room air.  The patient's body mass index was 28 and the patient denied pain or discomfort.  The patient was in no apparent distress with his listed medications consisting of ondansetron, Colace, oxycodone, and amlodipine.  The patient had seen their eye doctor and was sent for magnetic resonance imaging (MRI) of the orbits and brain, which were scheduled in 2 weeks. The patient claimed to have occipital headaches on the date of their visit to the emergency department and claimed that they only had double vision when both eyes were open.  The patient denied any other symptoms to include dizziness, vomiting, numbness, tingling, weakness, fever, chills, chest pain, or dyspnea.  The patient also denied a family history of aneurysm.  The patient was documented as ambulating with a steady gait in the emergency department and was pending MRI results with possible neuro consultation based on neurology results. 

The patient was subsequently admitted for further work-up whereupon the patient was sent to telemetry.  The MRI report indicated minimal periventricular and scattered subcortical white matter ischemia with mild to moderate pontine white matter ischemia.  The patient remained in inpatient status until discharge the following day after the patient was in stable condition.  The patient received a notice of adverse determination regarding the inpatient stay indicating that the evidence did not support the need for inpatient care.  The patient could have had care rendered on a lower level of service.  An appeal letter was received claiming that the patient was hypertensive at 177/95.  A head computed tomography (CT) was performed, and MRI of the head and orbits showed periventricular and scattered subcortical white matter ischemia and mild to moderate pontine white matter ischemia.  The patient was diagnosed with diplopia after being admitted to telemetry and required extended continuous cardiac monitoring.  An electrocardiogram showed sinus bradycardia with a heart rate of 58.  Once all risks were addressed and the patient achieved hemodynamic stability, the patient was cleared for discharge.  

The Milliman Care Guidelines indicated that admission to inpatient care may be supported when there is a hypertensive emergency indicated by a systolic blood pressure greater than 180 mmHg or diastolic blood pressure greater than 120 millimeters of mercury (mmHg) with evidence of acute or worsening target organ damage.  The information provided for the review stated that the patient's blood pressure on assessment in the emergency department was 177/95.  This did not satisfy the criteria for hypertensive emergency.  While it was reasonable for the patient to undergo additional work-up/testing with an associated care, the evidence did not support that the patient's care cannot be rendered safely and effectively on an observational basis or outpatient basis.  Given the provided information, the current request is not supported.  The inpatient hospital admission was not medically necessary.

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 inpatient hospital admission is not substantiated.