Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vertigo
Treatment: Inpatient admission
The insurer denied coverage for the inpatient admission.
The denial is upheld.

This patient presented to the emergency department with reports of dizziness. Past medical history significant for coronary artery disease, status post coronary artery bypass grafting (CABG), left ophthalmic lacunar infarct, four transient ischemic attacks, hypertension, hyperlipidemia, osteoarthritis, morbid obesity, and robotic assisted sleeve gastrectomy. The patient claimed that night before, he felt dizzy and as though the room were spinning. The patient took Excedrin, which helped, but awoke early with persistent symptoms. One episode of nausea was reported the night before and claimed that for the previous stroke, they felt similar dizziness and mouth numbness.  The patient was taking aspirin daily.  

On assessment, the patient was conversant, alert/oriented, with attention and comprehension intact. Recent and remote memory was intact, and they were able to ambulate with a steady gait and good balance. There was no vision impairment reported, was opening and closing his eyes symmetrically with no facial droop. Speech was fluent and intact with good shoulder shrug. The patient moved all extremities and had positive sensation. Vital signs were stable with blood glucose at 114.  A head computed tomography (CT) showed no intracranial hemorrhage or acute transcortical infarct. There was an old left thalamic lacunar infarct. Computed tomography angiogram (CTA) showed no large vessel occlusion and no significant stenosis or other occlusion. The patient was subsequently admitted to the stroke unit for further work-up with plans to obtain magnetic resonance imaging (MRI) of the brain without contrast and to rule out developing significant vertigo.

The Milliman Care Guidelines (MCG) state for neurology cases, the guidelines state that indications for admission to inpatient care include those individuals with encephalitis, severe central nervous system (CNS) infection, altered mental status that is severe persistent, mental status change requiring inpatient care, cerebral aneurysm requiring acute treatment, neurologic finding requiring inpatient care, ataxia, myasthenia gravis crisis or inpatient monitoring need, multiple sclerosis or other demyelinating disease exacerbation requiring inpatient care, intracranial hypertension, intracranial mass or process, Parkinson disease requiring inpatient care, and atrophic lateral sclerosis with inpatient care needs, severe neuropathy or neuromuscular disease, cerebral venous thrombosis, complications of congenital or degenerative disease not responsive to observation care, suspected or confirmed nerve toxin injury, neurologic trauma requiring inpatient treatment, complications of neurologic devices, isolation indicated that could not be performed outside the hospital setting, or neurologic condition, symptom, or finding for which observation care has failed or is not considered appropriate. Alternatives to inpatient admission include outpatient care in an Emergency Department, observation care, rapid treatment site, urgent care center, or medical office as well as home care, or a recovery facility.  

The information provided for the review did not support that the patient met any of the criteria for inpatient admission on either a cardiology aspect or neurology aspect.  

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 admission services is not substantiated.