Appeal type: Medical necessity
Decision: Upheld

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


This is a patient with a past medical history of migraines, hyperlipidemia, asthma, diverticulitis, multiple abdominal surgeries, and lumbar spine surgery, who presented to the emergency department with a sensation of horizontal spinning worsened with extension and rotation of her neck to the right with an episode of reported syncope without head trauma.
On presentation, she was afebrile with normotension, heart rate 66, respiratory rate 17, and oxygen saturation 99% on room air. A complete blood count and comprehensive metabolic panel were unremarkable. A computed tomography (CT) scan of the head showed no acute pathology. An electrocardiogram (EKG) noted no acute ischemia or arrhythmia. Despite symptomatic treatment with intravenous (IV) fluids, Reglan, Benadryl, and meclizine, the patient was unable to sit upright or ambulate without assistance. She was subsequently brought into the hospital with plans for ongoing symptomatic treatment and neurology evaluation.
Neurology saw the patient and recommended a magnetic resonance imaging (MRI) scan of the brain, physical therapy evaluation and ongoing treatment with as needed Valium, Benadryl, and meclizine. She remained hemodynamically stable. She continued to be dizzy.
The MRI of the brain was performed noting 2-3 millimeter (mm) cerebellar tonsillar ectopia. Prednisone was added given persistent dizziness.
Neurosurgery saw the patient and noted no neurosurgical involvement was needed for the patient. She walked 20 feet with physical therapy and home health physical therapy was recommended. The patient was continued on Prednisone, Valium, and meclizine.
At issue is the medical necessity of an inpatient level of care.
Inpatient stay was not medically necessary. This is a young patient who presented with vertigo. She was appropriate to bring into the hospital for further observation given her vertigo was refractory to numerous treatments in the emergency department and she required ongoing symptom control with inability to walk. It is noted, however, throughout her course she remained hemodynamically stable, continued on symptomatic therapies, with lab results normal, and with other work-up including MRI revealing 2-3 mm cerebellar tonsillar ectopia that did not require any acute intervention. She did not have another associated process contributing to the vertigo requiring inpatient treatment such as cerebrovascular accident, infection, or acute coronary syndrome, and while notes state that she had persistent dizziness, there are no physical therapy notes that the patient continued to be completely unable to ambulate or was unsafe to discharge. Given this, it is unclear why this young patient with acute vertigo requiring symptomatic treatment without other acute process contributing to vertigo requiring inpatient care could not have been safely cared for at a lower level of care.
In the absence of hemodynamic instability, severe persistent orthostatic hypotension, or other process such as cerebrovascular accident, acute coronary syndrome, or infection requiring inpatient care and leading to vertigo, and in the absence of physical therapy notes or progress notes clearly stating the patient not only continued to have dizziness but also persistent inability to walk. Inpatient care was not medically necessary.