Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Headache and left arm tingling
Treatment: Inpatient hospital admission 
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is a male. He was hospitalized for headaches and left arm tingling. He was directed to the emergency department for evaluation of frequent, intermittent headaches for the past few weeks associated with some left arm tingling and cold feeling. His past medical history is remarkable for hypertension, sleep apnea, BPH (benign prostatic hyperplasia), nephrolithiasis and carpal tunnel syndrome.

The patient's blood pressure was initially 163/106 and subsequently stabilized into the normal range. Physical exam was negative and neurological findings were noted to be normal. Brain CT (computed tomography) scan was unremarkable. EKG (electrocardiogram) showed sinus rhythm with new T-wave inversion in lead II. Troponin panel was negative. CT scan of the aorta was negative for dissection or aneurysm.

The patient's treatment included IV (intravenous) hydration and ARB (angiotensin II receptor blocker) using losartan for hypertension. The clinical impression was suspected migraine disorder and he was discharged to home.

This is an appeal of the denied claim the requested acute inpatient hospital stay was medically necessary for this patient.

No, the inpatient hospital admission was not medically necessary.

Based on the peer reviewed medical literature and this reviewer's expert medical opinion, there was not a medical need for the acute inpatient hospital stay because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. Criteria for inpatient hospitalization are not met, including severe headache that persists despite observation care, altered mental status that is severe or persistent, vomiting that is severe or persistent, dehydration that is severe or persistent, increased intracranial pressure, vasculitis, medication-overuse headache that has failed all outpatient management options, papilledema, cerebral edema, cerebral bleeding, mass effect on CT scan, pituitary apoplexy, hydrocephalus, seizures, anisocoria or IV (intravenous) fluids required. There was no hypertensive crisis, ischemic stroke, encephalitis, encephalopathy, hypertensive crisis, acute coronary syndrome (ACS), aortic dissection, acute myocardial infarction (AMI), hypertension requiring inpatient hospitalization or any other medical condition, symptom or finding for which a lower level of care had failed or was not considered appropriate. There was no clinical decline or inadequate response to treatment which required continuation of the hospital stay past a lower level of care. The care the patient received for suspected tension headaches like in this case, is routinely provided safely and effectively at a lower level of care. Therefore, the inpatient hospital admission was is not medically necessary based on the submitted information and the current published medical literature.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.

There was no clinical decline or inadequate response to treatment which required continuation of the hospital stay past a lower level of care. The care the patient received for suspected migraine disorder like in his case, is routinely provided safely and effectively at a lower level of care.