Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vertigo
Treatment: Inpatient hospital admission
The insurer denied coverage for an inpatient hospital admission.
The denial is upheld.

This case involves an adult female who presented to the emergency room with complaints of headaches and vertigo that have been worsening over the course of 2 weeks. She reported symptoms for 3 years, but claimed that for the past several weeks, meclizine was not working. Symptoms were waxing and waning and worsened by turning the head, sitting upright, and standing. Associated symptoms included headaches. Exam findings showed stable vital signs with mild erythema of the left ear canal. The patient was rating her headaches at 9-10/10 associated with blurry vision, photophobia, and phonophobia and feelings of dizziness. The patient was documented with enlarged tonsils and had plans for tonsillectomy as it was affecting her breathing. She claimed that a sleep study was negative for obstructive sleep apnea. In addition to headaches and vertigo, the patient was diagnosed with blepharitis. A computerized tomography (CT) of the head without contrast was obtained noting a small focal hypodensity in the right pons, which could be artifactual. There were no other abnormalities noted. Magnetic resonance imaging (MRI) of the brain was also unremarkable. Records indicated that the patient's headache fit into many differential diagnoses including migraine with aura, given her photophobia and phonophobia versus idiopathic intracranial hypertension, given her weight gain, constant headache, and vision changes. Stroke was unlikely given that the patient did not have any risk factors and her symptoms were acute on chronic. Throughout her course of care, she received intravenous Metoclopramide, diphenhydramine, ketorolac, along with Tylenol, ibuprofen, heparin, and lorazepam.

The Milliman Care Guidelines state that clinical indications for admission to inpatient care for those individuals who present with headaches include those who have severe headaches that persist despite observation care, when they have altered mental status that is severe or persistent, vomiting that is severe persistent, dehydration that is severe persistent, unruptured but symptomatic aneurysm, dissection, or vascular malformation, venous sinus thrombosis, increasing intracranial pressure, cerebrospinal fluid leak, medication overuse headache at that has failed all outpatient management options, vasculitis, severe neurological findings, new onset focal neurologic deficit, intravenous fluid requirement, or increased intracranial pressure or cerebral edema monitoring needed. The evidence did not support that the patient met any of these criteria requiring inpatient care. She could have had her assessments, diagnostic testing, and treatment rendered on an outpatient or observational basis. Her vital signs were relatively stable with no evidence of any neurological dysfunction.  

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

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