Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Headaches, and Ventriculomegaly and Mastoid inflammation. 
Treatment: Inpatient admission. 

The insurer denied coverage for the inpatient admission. 

The denial is upheld. 

This is a female patient who presented to the Emergency Department (ED) with complaints of a chronic headache.  The documentation indicated the patient has a history of head trauma with an abnormal magnetic resonance imaging (MRI).  The patient had complaints of dizziness and headaches, and was sent from her neurologist's office for further evaluation of symptoms.  The patient's outside MRI revealed ventriculomegaly and mastoid inflammation.  The patient did indicate that her initial injury was due to a piece of sheet rock falling on her head.  The patient had been experiencing intermittent headaches since the date of injury.  The patient's physical exam revealed a blood pressure 121/71 with a pulse of 67.  The patient's computed tomography (CT) scan of the head revealed the ventricular caliber was within normal limits; there was no intracranial mass lesion or focal mass-effect.  The physician indicated that the patient should undergo a neurology consultation as well as a repeat MRI and laboratory studies.  The documentation detailed the patient did undergo a neurology consultation where an additional MRI was ordered.  The repeat MRI revealed mildly prominent ventricles for which a lumbar puncture was recommended.  As per documentation, the lumbar puncture was attempted however, was not able to be performed.  The patient was treated with multiple medications with concern for papilledema.  The patient continued with additional treatment that included multiple medications and intravenous (IV) fluids. Additional consultation was undertaken with otolaryngology.  The physician indicated that the patient's findings were not consistent with mastoiditis.  The patient continued to improve and was discharged with instruction to follow-up as an outpatient. 

According to current literature a patient may be admitted when there is severe headache persisting despite observation care treatment, altered mental status and/or severe persistent vomiting, dehydration that is severe or persistent or there is evidence of severe new neurologic findings requiring inpatient care.  Additionally, if there is evidence of encephalitis, the patient may also be admitted. 

In this case, the patient was referred to the ED for further evaluation of an abnormal MRI and complaints of a headache.  The patient presented however without significant findings on physical examination.  Furthermore, the patient's laboratory and diagnostic studies were performed and did not reveal any acute significant abnormalities that would warrant an inpatient admission.  The patient did undergo multiple consultations however, it is unclear why the patient could not undergo a consultation while in observation status.  Therefore, given the lack of findings concerning for significant acute pathology warranting an inpatient level of care, inpatient admission is not considered medically necessary for this patient. 

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient. 

The medical necessity for the inpatient admission is not substantiated.  The insurer's denial should be upheld.