Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Headaches
Treatment: Inpatient Admission
The insurer denied: Inpatient Admission
The denial is: Overturned

The patient is a male with asthma and polysubstance abuse who was brought to the emergency department with complaints of headaches for two days on the right forehead. It was sharp and stabbing with associated nausea and vomiting. The headache is similar to previous episodes, with unclear triggers. The patient reported an altercation two months before this presentation where the patient was hit on the head with a stick, suffering a laceration requiring sutures. Vital signs in the emergency department (ED) revealed a temperature of 97.7, a heart rate of 104, and a blood pressure of 154/89. Oxygen saturation was 99% (percent) on room air. Labs were remarkable for normal complete blood count (CBC), mild hypokalemia, and normal kidney function. liver function tests (LFTs) were mildly elevated, with aspartate aminotransferase (AST) at 283 and alanine aminotransferase (ALT) of 51, consistent with an alcohol ingestion pattern. Lactic acid was elevated to 3.3, and magnesium was 1.4. The ethanol level was 180. The patient tested positive for coronavirus 2019 (COVID).

He was admitted to the hospital with a principal headache diagnosis, inducing nausea and vomiting. He was treated with intravenous (IV) Toradol. The medical team ordered a computed tomography (CT) scan of the head and started the patient on saline. Repeat labs were ordered, and the electrolytes were replaced. They also were worried about alcohol withdrawal, and the Clinical Institute Withdrawal Assessment (CIWA) scale was calculated to 4 mainly because of the headache. He was given scheduled Librium and, as needed, Ativan. In addition, the medical team ordered a right upper quadrant ultrasound. For the positive COVID, he was placed on contact, and droplet isolation and inflammatory markers were ordered as well. A loading dose of Remdesivir was given as well, as daily Remdesivir was scheduled.

Additionally, a neurology consultation was obtained for persistent headaches. The neurologist recommended continuing dexamethasone, ketorolac, and magnetic resonance venography (MRV) of the head to rule out thrombosis. Later in the evening, the patient left against medical advice (AMA), returned an hour later complaining of syncope, and wanted to be admitted again. His score was 5. Treatments were reinitiated; however, a few hours later, the patient decided to leave AMA again.

After carefully reviewing the provided documentation, the inpatient admission was medically necessary. The patient has multiple medical conditions that require an inpatient stay, including COVID infection with hypoxemia, possible concurrent bacterial infection, liver injury with cirrhosis and possible cholecystitis, ascites, and thrombocytopenia. Persistently elevated inflammatory markers confirm active severe COVID illness. In addition, the patient was experiencing symptoms of moderate alcohol withdrawal and required treatment with benzodiazepines to prevent delirium tremens. This could not be accomplished under a lower level of care status, and inpatient admission is indicated.