Appeal type: Medical necessity
Decision: Upheld

The patient is a male with a past medical history significant for chronic back pain, asthma, gastroesophageal reflux disease (GERD), ulcerative colitis, hepatitis B, chronic anemia, seizures, and alcohol abuse who presented to the emergency department after he had a fall. Reportedly, the patient was in his usual state of health until the day of admission.
The patient could not remember any events surrounding the incident. At the time of admission, the patient denied being intoxicated.
Following the fall the patient noticed a pain in the neck, head, and left knee. He also developed dizziness. He denied any weakness in his limbs or any sensory changes, speech, or swallowing difficulties.
A review of systems obtained on admission was also negative for fever, headache, palpitations, cough, abdominal pain, urinary changes. The patient admitted to the use of alcohol but denied any illicit drug use.
At the time of initial evaluation patient's temperature was 99.0, pulse rate 103, respiratory rate 18, and blood pressure 115/70, with an oxygen saturation 95% on room air. The rest of the physical exam, which included a cardiac exam and neuro exam, was within normal limits.
At the time of initial evaluation in the emergency department, the patient underwent a computed tomography (CT) scan of the head, cervical spine, maxilla. Those studies did not show any evidence of fracture or bleed.
Electrocardiogram (EKG) demonstrated normal sinus rhythm, first-degree atrial ventricular block, no evidence of ischemia.
A chest x-ray showed no evidence of acute cardiopulmonary disease.
Laboratory evaluation revealed that the patient's white blood cell count was 4.8, hemoglobin 8.5, hematocrit 28.9, platelets 169. Sodium was 133, potassium 4.0, chloride 99, bicarbonate 19, blood urea nitrogen (BUN) 7, creatinine 0.96. Urinalysis was unremarkable. Cardiac enzymes were within normal limits. The patient's urine drug screen came back positive for cocaine. The serum ethanol level was 66 on presentation.
As a result of the fall, the patient sustained a head injury including scalp laceration, which was repaired in the emergency department.
The patient was admitted to the hospital with a diagnosis of head trauma, chronic iron deficiency anemia, cocaine abuse, hepatitis B, asthma, forehead laceration, alcohol intoxication, seizure disorder.
In the hospital, the patient was seen by a neurologist who recommended the initiation of meclizine for dizziness. Apparently, as a result of the head trauma, the patient developed some conjunctival hemorrhage, which was asymptomatic.
Since the maxillofacial CT showed that the patient could have a dental abscess, he received treatment with antibiotics.
At the time of discharge, the patient was in overall stable clinical condition.
The subject under review is the medical necessity of the inpatient stay.

The health plan's determination is upheld.

This patient presented to the hospital after he sustained a fall. At the time of the presentation to the emergency department, he had high serum ethanol level and he was also positive for cocaine.
Most likely the patient had a fall as a result of the drug and alcohol intoxication. There was a possibility that the patient had a seizure or other conditions leading to a fall.
However, at the time of admission and during the hospitalization, he remained afebrile and hemodynamically stable. The results of laboratory studies were reassuring. Even though the patient had chronic anemia, there were no signs of active bleeding, and his hemoglobin and hematocrit (H&H) remained stable.
The patient was afebrile and hemodynamically stable. On the neurological exam, he was awake, alert, and oriented 3. The patient had no focal neurological deficits. His laboratory results remained stable. There was no evidence that the patient had alcohol withdrawal symptoms. For the dental abscess, the patient received treatment with oral Clindamycin.
According to the records, one of the main problems why the patient stayed in the hospital for so many days was dizziness, which was attributed to a recent fall. Regardless, dizziness itself is an uncommon reason for an inpatient hospital stay in the setting of a normal neuro exam and reassuring imaging studies.
The requested health service/treatment of inpatient hospital stay was not medically necessary for this patient at the acute inpatient level of care. The patient was admitted with a scalp laceration following a fall/syncopal episode.
At the same time, the patient remained hemodynamically stable, his cardiovascular exam and neurological exam were normal. There were no indications of any fractures, hematomas, or any acute changes in the diagnostic studies, which included a CT scan of the head.
Taking into consideration all these facts the patient could have been treated at a lower level of care status.