Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Inpatient Hospital. 

The Insurer denied the inpatient hospital admission for medical necessity. The denial was upheld. 

The patient is a female with a past medical history significant for gastroesophageal reflux disease (GERD) and asthma who was admitted  after she presented with complaints of headache that started several hours before her presentation. The headache was associated with right facial weakness and epigastric tenderness. The patient described the pain as severe and bitemporal. The patient thought that the headache resembled migraines.
When seen by the admitting physician the patient was afebrile, heart rate was 70, respiratory rate was 20, blood pressure was 121/62, and oxygen saturation was 99% on room air. The patient was alert, in no distress, and somewhat lethargic. The neck was supple without lymphadenopathy, masses, jugular vein distention (JVD), or carotid bruits. The patient had a regular rate and rhythm, without murmurs, rubs, or gallops. She was alert and oriented times (x) 4. The rest of the physical exam was unremarkable.
Her laboratory evaluation revealed that her sodium was 140, potassium was 4.1, chloride was 104, bicarbonate was 28, blood urea nitrogen (BUN) was 13, creatinine was 0.66, and glucose was 101. Her white blood cell count was 8.21, hemoglobin was 13.2, hematocrit was 39.9, and platelets were 269. The liver function tests were within normal limits. The rapid influenza screening test was negative. A computed tomography (CT) scan of the head showed no acute intracranial hemorrhage or mass effect. A CT angiogram of the carotid arteries and circle of Willis was also unremarkable.
The patient was admitted to the hospital to rule out cerebrovascular accident (CVA). In the hospital, the patient was seen by a neurologist who recommended ruling out a complicated migraine. A magnetic resonance imaging (MRI) scan of the brain was recommended. It was performed and interpreted as an unremarkable study in regard to an acute cerebrovascular accident. The patient received treatment with Dexamethasone and her headache resolved.
During the hospital stay the patient remained in stable clinical condition. Since her symptoms resolved, she was discharged home.
At issue is the medical necessity of the inpatient stay.
The health plan's determination of medical necessity is upheld in whole. 
The requested health service/treatment of inpatient stay was not medically necessary for this patient.
According to the generally accepted standards of care, admission at the inpatient level of care is indicated for people who present with headaches that persist despite observation care treatment, and for patients with severe or persistent altered mental status, severe or persistent vomiting, or severe or persistent dehydration.
Admission at the inpatient level is generally indicated in cases of headache associated with unruptured but symptomatic aneurysm, or vascular malformations, venous sinus thrombosis, increased intracranial pressure, cerebral spinal fluid leak, medication overdose-induced headache, vasculitis, or in cases when patients present with neurological findings including papilledema, cerebral edema, mass effect on CT scan, cerebral bleeding, ischemia or vasospasm, hydrocephalus, or uncontrolled seizures.  Other indications for inpatient admission include new onset of persistent focal neurologic deficits, cerebral bleeding, hydrocephalus, and increased intracranial pressure. The review of the medical records demonstrated that in this clinical case none of these conditions were present for this patient.
Overall, the patient remained in stable clinical condition. There was no need for diagnostic studies or procedures necessitating the inpatient level of care.
Therefore, the inpatient level of care was not medically necessary.