Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Inpatient Hospital. 
The insurer denied: Inpatient hospital admission. 
The denial is upheld.

The patient is a female who presented to the emergency department with concerns for dizziness. Pertinent history included dyslipidemia and obesity. Initial vital signs revealed a temperature of 97.3 Fahrenheit (F), heart rate (HR) 65, blood pressure (BP) 146/92, respiratory rate (RR) 18, and peripheral capillary oxygen saturation (SpO2) of 96% on room air. Initial examination documented the patient as alert, oriented, with left-sided fatigable horizontal nystagmus, and without vertical nystagmus. Initial serology revealed a white blood cell (WBC) count of 8.7, hemoglobin (Hgb) of 12.5, and platelets (Plt) 315. Blood urea nitrogen (BUN) was 10, creatinine (Cr) was 0.9, sodium (Na) was 139, potassium (K) was 4.3, calcium (Ca) was 9.7, glucose (Glu) was 114, and magnesium (Mg) of 2.3. Troponin I was 0.00. Urinalysis was unremarkable. Electrocardiogram (EKG) revealed sinus rhythm with first-degree atrioventricular (AV) block and a corrected QT interval (QTc) of 494 milliseconds (ms). There was no notable acute ischemic changes, ectopy, arrhythmia, or heart blocks of significance. Computed tomography (CT) of the head was unremarkable. Meclizine, lorazepam, Reglan, and intravenous fluids were provided with improvement. The patient was admitted with an impression of Vertigo. Treatment plan included intravenous fluids, meclizine, Reglan, and consultations.
The next day the patient remained afebrile and hemodynamically stable. An echocardiogram was performed which did not reveal significant abnormalities. Neurology consultation was obtained who had an impression of presyncope likely due to vasovagal secondary to dehydration versus vertigo. Recommendations included an increase in meclizine, continuous cardiac monitoring, and ear, nose, and throat (ENT) follow-up. Repeat EKG revealed improvement in QTc. No other issues or complications were documented. The patient was deemed medically stable and discharged to home. The subject under review is the medical necessity for the inpatient hospital admission.

The health plan's determination is upheld. 

Inpatient hospital admission was not medically necessary for this patient based on the clinical documentation provided, evidence based literature and standards of care. Evaluation and management could have been completed at a lower level of care status.
The patient had no significant medical history and presented with concerns of dizziness. The patient was afebrile and hemodynamically stable. Initial examination noted the patient to be alert, oriented, with horizontal nystagmus, and without significant neurological deficits. Serology unremarkable. EKG revealed sinus rhythm without ectopy, significant conduction deficits, or acute ischemic changes. The QTc was noted to be prolonged at 494 ms. Repeat EKG noted the prolonged QTc to have resolved without directed treatment. CT of the head was unremarkable. Treatment thereafter included intravenous fluids, meclizine, and Reglan. No other issues or complications were documented. Following observation care, the patient was deemed medically stable for discharge to home.