Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vertigo
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The health plan's determination is upheld.

The patient is a female who initially presented to the emergency department with concerns for dizziness. Her pertinent history included vertigo, hypertension, diabetes mellitus, and epilepsy. The initial vital signs revealed a temperature of 98, heart rate (HR) 71, blood pressure (BP) 160/87, respiratory rate (RR) 17 and her peripheral capillary oxygen saturation (SpO2) 98 percent (%) on room air. The initial examination documented the patient as alert and oriented without focal neurologic deficits. The initial laboratory testing revealed a white blood cell count (WBC) 6.8, hemoglobin 11.8, platelets (Plt) 312, sodium 139, potassium 3.6, glucose 130, blood urea nitrogen (BUN) 15, creatinine 0.9 and her brain (or B-type) natriuretic peptide (BNP) was 87. The urinalysis was unremarkable. The venous blood gas was unremarkable. Her lactate was 3.2.
The electrocardiogram (EKG) was unremarkable and it was unchanged from the prior EKG. The chest x-ray (CXR) was unremarkable. The patient was placed in the hospital thereafter with an impression of dizziness. The treatment plan included additional laboratory testing, computed tomography (CT) of the head imaging, and a physical medicine and rehabilitation (PM&R) consultation. The PM&R consultation was done and provided a discharge recommendation of home with family support. The CT of the head was unremarkable for acute pathology. The patient's dizziness had resolved. A Foley catheter, that was placed in the emergency department for urinary frequency, was removed without issue. There were no significant changes in treatment. The treatment plan shifted to obtain additional diagnostic tests for myalgias and radiculopathy. There was no significant change in the treatment plan. The patient then complained of decreased hearing and itchiness to the left ear. Ear, nose, and throat (ENT) was consulted and noted the issue had self-resolved. Recommendations were to avoid ear plugs for sleep. The weakness was documented as resolved. The patient was seen ambulating on her own. The patient was discharged thereafter.

The patient presented to the emergency department with complaints of dizziness, nausea, and urinary frequency. The initial examination documented the patient alert, oriented, hemodynamically stable, and without focal neurologic deficits. Laboratory testing was essentially unremarkable. The electrocardiogram was unremarkable. The chest radiograph and CT of the head were relatively unremarkable. There were no documented objective findings that suggested the presence of an acute pathological process requiring urgent intervention. In addition, no urgent intervention was performed. The treatment plan consisted primarily of therapy services and additional diagnostic testing to pursue additional subjective complaints. No other issues or complications were documented.
Clinical indications for admission to inpatient care were not met. The patient did not have acute bacterial labyrinthitis, cerebellar, brainstem, cerebral ischemia or hemorrhage, suspected etiology that requires admission for treatment (e.g., vertebral artery dissection), hemodynamic instability, signs of symptoms that are severe and persistent (e.g., inability to ambulate after observation care treatment) or persistent vomiting. The patient did not have cardiac arrhythmias of immediate concern, severe (new) neurologic findings requiring inpatient care (papilledema, cerebral edema, mass effect, cerebral bleeding, ischemic, or vasospasm, increased intracranial pressure or hydrocephalus), continuous intravenous infusion of anticoagulation, platelet inhibitor, vasoactive, or antiarrhythmic medication, or other condition, treatment, or monitoring requiring inpatient admission.[2]

The health plan's determination of medical necessity is upheld in whole.