Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dizziness. 
Treatment: Full hospital admission. 
The insurer denied coverage for the full hospital admission. 
The denial is overturned. 

This case involves a patient who presented to the emergency department for evaluation of nausea and vomiting that was present for 2 days with severe dizziness after taking losartan, and worsening of symptoms when opening their eyes. The patient was noted to have a medical history of enlarged prostate, gastroesophageal reflux disease, hypertension, hyperlipidemia, nasal polyps, and sinusitis. On exam, the physician noted difficulty testing cranial nerves 3, 4 and 6, with cranial nerves 5, 7-12 intact, sensation and motor strength intact, and blood pressure of 133/48. The treating physician stated that it was medically necessary for the patient to be admitted inpatient due to concern of vestibular neuritis. A computerized tomography (CT) of the head noted mild ethmoid sinus disease. The patient underwent a neurology consultation, with notes of a wide based and ataxic gait on exam, as well as assistance needed to ambulate. Lab results dated a glucose of 132, white blood cell count (WBC) of 11.6, hemoglobin (HGB) of 13.5, and hematocrit of 39.5. The treatment plan included a magnetic resonance imaging (MRI) of the brain due to concern for a brainstem or cerebellar infarct. The patient was seen for cardiology consultation with no concern of cardiac etiology noted, however, the patient was stated to be unsteady on feet. It was noted that the patient's vertigo symptoms had subsided, however, the patient continued to have difficulty walking, and was pending a brain MRI. The patient was treated with aspirin, atorvastatin, enoxaparin, losartan, meclizine, ondansetron, and pantoprazole. It was noted that the patient was alert, oriented, and stable, with no complaints of dizziness. The patient ambulated in the hallway with physical therapy. The patient was discharged home with plans for vestibular therapy, and a follow-up visit with the patient's primary care provider. 

Evidence based literature indicates extended stay may be needed for evaluating and treating specific causes of dizziness, including severe acute vestibular neuronitis, with a brief stay extension of 1-3 days to provide antiemetics, antihistamines, IV (intravenous) hydration, and IV steroids. Additional literature states the typical treatment for vestibular neuritis often consists of antiemetics, antihistamines, and benzodiazepines, and it is necessary for clinicians to differentiate the condition from other central causes such as cerebrovascular syndromes. Additional evidence based literature states there is no definite test for acute unilateral vestibulopathy, and as such, the diagnosis requires exclusion of central lesions and other disorders. The patient presented to the emergency department with symptoms of nausea, vomiting, dizziness, and vertigo, as well as an ataxic gait and central vertigo on exam. The treating physician noted concern of brainstem or cerebellar infarct and as such, the patient underwent further imaging to rule out serious acute neurological conditions. Once it was determined that the patient had vestibular neuronitis, the patient was treated appropriately with IV fluids, antiemetics, and antihistamines, as well as physical therapy. The patient was then able to ambulate in the hallway with physical therapy, and was discharged home shortly after. The patient was thoroughly evaluated and monitored based on the patient's condition, and the length of inpatient stay was medically appropriate due to the severity of the patient's symptoms from vestibular neuronitis. As such, the request of full hospital admission is medically necessary, and the denial is overturned. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for full hospital admission is substantiated.