Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Headaches with double vision and gaze palsy.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a male. The patient had headaches with double vision and gaze palsy due to a left 6th nerve palsy. A whooshing was present in his left ear with pulsatile tinnitus. A MRI/MRA (magnetic resonance imaging/ magnetic resonance angiography) diagnosed a potential dural arteriovenous fistula (AVF) involving the left cavernous sinus.

Yes, the Inpatient admission was medically necessary.
Neither the Society of Neurointerventional Surgery (SNIS), the American College of Radiology (ACR), nor the Society of Interventional Radiology (SIR) have specific guidelines for postoperative care for intracerebral interventions. The ACR (American College of Radiology) ASNR (American Society of Neuroradiology) SIR (Society of Interventional Radiology) SNIS (Society of Neurointerventional Surgery) Practice Parameter for the Performance of Diagnostic Cervicocerebral Catheter Angiography in Adults states, "Relative Contraindications to Short-Term Observation: Several factors must be considered when determining the length of postprocedure observation. Some of the relative contraindications to short-term observation are listed below. This list is not meant to be comprehensive, and any clinical circumstance that may occur around the time of the procedure and might predispose the patient to or result in a significant complication should prompt prolonged observation or hospitalization.
1) Patients with poorly controlled hypertension in which there appears to be increased risk of hematoma formation
2) Patients with significant risk of contrast media associated nephrotoxicity
3) Patients with coagulopathies or electrolyte abnormalities that require correction
4)Insulin-dependent diabetics who have labile serum glucose levels in the periprocedural period
5) Patients with complications occurring during or after arteriography, including bleeding, anuria, persistent nausea, and vomiting
6) Patients who exhibit hemodynamic instability or significant arrhythmia during or after the procedure

"Furthermore, prolonged observation or postprocedural hospitalization should be considered when travel time to the hospital or to another acute care facility is >30 minutes from where the patient is to spend the first postprocedure night, or for patients who live alone.
The patient underwent an uncomplicated cerebral angiogram, and a left carotid cavernous fistula embolization was performed. The patient was admitted and had bedrest for six hours following the procedure. He remained stable. The patient remained stable, and the arterial access site was without hematoma. The patient tolerated oral fluids and food and was at baseline with no complaints.

"The decision for short-term or longer-term postprocedure observation must be individualized, and a patient's care may vary from the above criteria for sound clinical reasons. The diagnostic neuroangiographer and referring physician must make the decision in each case after reviewing all pertinent data."

This patient had a diagnostic cerebral angiogram and an uncomplicated intracerebral embolization and post-operative course, with stable vital signs. He readily progressed to ambulation and PO (oral) intake. The risk of an intracerebral intervention is much higher than just diagnostic cerebral angiography, and employing those above guidelines, it is up to the physician to make the decision for a longer hospital stay for each case. This decision making should be taken one higher step when dealing with an intracerebral intervention. Even though the patient was stable, the risk of a catastrophic event is high. Being in an inpatient setting would allow quick and potential life-saving interventions. The decision making should be left to the neurointerventionalist, who decided that an inpatient one day stay was medically necessary.

Therefore, given the above, the Inpatient admission was medically necessary.