Appeal type: Medical necessity
Decision: Upheld

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

According to the medical records, this is a patient who presented with complaints of severe headache that began the previous day. The patient had migraines, and the current migraine was located in the back of the head with radiation down the back of the neck. The patient also had intermittent presyncope with nausea and vomiting, but no fevers. History was significant for migraines, polycystic ovarian syndrome, fibromyalgia and anxiety. Examination revealed normal appearance, head, eyes, ears, nose, and throat (HEENT), cardiovascular, pulmonary, abdominal, musculoskeletal, skin, mental status, cranial nerve, sensory, motor, gait, coordination, Romberg, and psychiatric examinations. Chest x-ray was negative. A head computed tomography (CT) scan revealed no hydrocephalus, acute intracranial hemorrhage or mass effect. The patient complained of chest pain, and the plan was to have a cardiac catheterization. The patient was to be admitted to have a cardiac catheterization. Troponins were negative. The patient had no further neurological treatment while hospitalized with the exception of management of the patient's headaches. The patient was not on any form of monitoring. The patient's headaches improved while hospitalized, and the patient was discharged.

The patient did not require an acute level of care. The patient could have been treated in the emergency department or under observation, with appropriate analgesics and subsequently discharge an acute intracranial process was ruled out. The patient did not meet Milliman Care Guidelines criteria as there is no acute visual loss, inadequate oral intake, intractable nausea/vomiting or a change in mental status. The patient therefore did not meet criteria for admission and could have been discharged from the non-acute setting (emergency department or observation).

"The acute headache in the emergency department (ED) poses a diagnostic dilemma that may overwhelm providers attempting to weigh the cost of advanced workups against the risk of missing serious pathology. While the majority of headache concerns are benign primary headache disorders, identifying life-threatening secondary causes of headache-which may be broadly categorized into structural, infectious, and vascular causes-is the primary focus of evaluation in the ED" (2).

"Most patients presenting with headache in the ED will have migraine, but red flags must be reviewed to rule out secondary headaches. SM refractory to home treatment is a common reason for ED presentation or inpatient admission, but high-quality treatment evidence is lacking. Common treatments include intravenous fluids, anti-dopaminergic agents with diphenhydramine, steroids, divalproex, nonsteroidal anti-inflammatory drugs, intravenous dihydroergotamine, and nerve blocks. Other therapies (e.g., ketamine and lidocaine) are used with limited or inconsistent evidence. There is evidence for inpatient behavioral management therapy. This article details red flags to review in the workup of headache presentation in the ED and provides a step-wise approach to ED and inpatient management. However, more studies are needed to better optimize care" (3).

"Headache is a nearly universal complaint. Most headaches are benign, and most patients can be safely treated and discharged with minimal workup. However, many serious and life-threatening conditions may present with headaches. Recognition, evaluation, and appropriate management of these dangerous secondary headaches are critical to preventing long-term disability or death" (1). 

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 an inpatient admission is not substantiated.