Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Torticollis
Treatment: Inpatient admission 
The insurer denied coverage for the inpatient admission.
The denial is upheld.

This patient was admitted to the hospital with complaints of neck pain, and complained that her neck was stuck with her head leaning to the left side. She complained of a syncopal episode early in the day with loss of consciousness and awakening on the floor and had urinated on herself. She also complained of numbness in her lips on the left upper extremity. In the emergency department, the neck was noted to be contracted to the left with decreased sensation in the left arm, with left upper extremity strength of 3/5. She complained of numbness in her lips and left arm. She indicated that the loss of consciousness was associated with urinary incontinence. When seen in the emergency room, she denied any current numbness, tingling, weakness, dizziness, slurred speech, or any other neurological symptoms. She was admitted to a telemetry level of care.

The initial medical decision-making in the emergency room was neck pain/torticollis and syncope, with no clear precipitant of the torticollis. There was no tongue biting or defecation. Examination was significant for pathologic hyperreflexia, a left hemisensory disturbance and asymmetric weakness on the left compared with the right with the right upper extremity essentially plegic, the right lower extremity severely week and with near-normal strength on the left. A head computed tomography (CT) scan performed on presentation was negative for acute changes. CT (computed tomography) angiography of the neck and brain were negative. She was initially treated for dystonia and associated pain, with benztropine, Valium, and ketorolac. She was subsequently admitted. Diagnostic workup included an electroencephalogram (EEG) that was performed and was normal. A cervical spine MRI (magnetic resonance imaging) revealed no evidence of acute cervical spine fracture, the significant rotation at the atlanto-axial joint type I that was due to neck positioning. She was discharged with a diagnosis of torticollis. 

Bevers et al (2017), "Ischemic stroke accounts for approximately 85% of all strokes. Although severe strokes constitute a minority of cases, they are associated with a majority of the subsequent disability and death. Reperfusion therapy with intravenous tissue plasminogen activator (tPA) and/or endovascular thrombectomy is a mainstay of acute stroke management. Intensive care management of stroke is focused on reducing complications of reperfusion such as hemorrhagic transformation, and minimizing secondary brain injury, including brain edema and progressive stroke. Additionally, severe stroke patients frequently need ventilatory or hemodynamic support provided in an intensive care unit (ICU) setting. Here, we discuss the current medical and surgical ICU management aspects of acute ischemic stroke and identify areas where ongoing studies may reveal new treatments to improve neurological recovery."

Copley et al (2016), "This article reviews fractures of the cervical spine, highlighting the pertinent goals of initial management, the indications for different imaging modalities and the different fracture patterns. Basic principles of management of these different fracture patterns are outlined."

Vu et al (2021), "HT (head tremor) severity was associated with longer CD (cervical dystonia) duration (p (probability) < 0.0005), whereas pain severity was associated with younger age at onset (p = 0.043). HT severity and pain severity were not correlated for jerky HT (p = 0.996), but positively correlated for regular HT (p = 0.01)."

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

The insurer's denial of coverage for the inpatient admission is upheld. Medical Necessity is not substantiated.