Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Headache

Treatment: Inpatient admission

The insurer denied coverage for an inpatient admission
The denial is upheld.

This case involves a female who presented to the hospital. The patient had a history of asthma and ventriculostomy secondary to obstructive hydrocephalus caused by tectal glioma. She reported that her symptoms were similar though slower onset, less severe, and longer lasting than when she experienced prior to reopening procedure the previous year. Vital signs on the patient were documented as blood pressure 123/77, pulse of 88, temperature 36.7  C (degrees Celsius), respiratory rate of 18, weight of 195 pounds, and oxygen saturation of 98% (percent).  She was active and in no acute distress. Her pulmonary effort was normal. The patient presented with increased lethargy and sleep duration as well as increased headaches for the past week. She reported shortness of breath that have been ongoing for the last 2 days that required albuterol. She reported that she had a severe headache the previous day that was relieved somewhat with Motrin. She denied any photophobia. Her neurological exam was intact. Magnetic resonance imaging with cerebrospinal fluid flow showed patent third ventriculostomy with stable ventricular caliber.  

Per the cited sources, indications for admission for evaluation of headache includes severe pain that persisted despite observation care, altered mental status that is severe or persistent, dehydration that is severe or persistent, increased intracranial pressure, and for severe new neurological findings requiring inpatient care such as new onset focal neurological deficit. In this case, the patient presented to the hospital with complaints of headache and lethargy.  She had a history of asthma and ventriculostomy secondary to obstructive hydrocephalus caused by tectal glioma. It was argued that the inpatient admission was medically necessary. The decision of the treating practitioner to admit to and treat the patient in the inpatient setting was made by the real-time evaluation of the severity of the presenting symptomatology coupled with persistence of symptoms despite initial aggressive management. Per MCG (Milliman Care Guidelines), inpatient admission was indicated for patient presenting with persistent severe headache. The patient presented with headache, lethargy, and sleepiness. The treatment plan included imaging and monitoring. Thus, the decision to admit the patient was medically indicated, reasonable, and consistent with evidence-based practice. However, the documentation did not reveal that the patient had severe pain that persisted despite observation care. The documentation did not reveal altered mental status that was severe or persistent, dehydration that was severe or persistent, or new onset focal neurological deficits. Thus, the patient's care could have been completed at a lower level such as observation. As such, the denial of coverage for inpatient admission was appropriate and is upheld.

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.