Diagnosis: Headache with nausea and vomiting
Treatment: Inpatient Hospital

Summary: This patient presented to the Emergency Department (ED) complaining of a headache as well as nausea and vomiting. The patient did arrive via emergency medical services who indicated they gave the patient 4 mg of Zofran. The patient had an episode of emesis during triage. The documentation details the patient has a history of prolonged complex seizure. He was mildly confused but able to answer questions and was re-directable. On physical exam he was oriented to person place and time and was in no acute distress. The documentation detailed they were unable to get a good neurological examination as the patient was nauseous and vomiting. It was recommended the patient undergo multiple laboratory and diagnostic studies. The physician detailed the patient's vitals were stable on presentation and he was given a fluid bolus as well as Zofran, Toradol and Reglan. The patient did have improvement. Laboratory studies to include a comprehensive metabolic panel (CMP) and complete blood count (CBC) were reassuring against meningitis. It was recommended the patient be admitted per pediatric neurology and undergo video electroencephalogram (EEG). The patient's numbness did resolve and headaches were improved. Neurology was able to get a neurological examination that did not reveal any significant abnormalities. The patient was neurologically intact to include mentation. He continued with treatment. The patient did not have any acute events overnight and the EEG performed showed slowing present in the right posterior region with no epileptiform activity noted. The diagnosis was likely acute episode of migraine without aura and it was recommended the patient undergo an additional EEG in 3 months. The patient was discharged the following day in stable condition.

The insurer has denied coverage for the inpatient hospital admission as not medically necessary. The denial was upheld.

According to current literature, a patient may be admitted to inpatient services when there is evidence of severe central nervous system (CNS) infection, vasculitis, cerebral aneurysm, myasthenia gravis crisis, multiple sclerosis, complications of neurologic devices, or evidence of hemodynamic instability, complex febrile seizure, status epilepticus or repetitive seizures that are not controlled with emergent treatment or there are new focal neurologic deficits. Within the documentation, there was no indication of the above. While it was noted the patient continued to have symptoms while in the ED, the physician detailed the patient did improve with medication. There was no indication of why the patient could not have been observed at a lower level such as observation. Therefore, given this is not consistent with current literature the previous denial of coverage for the inpatient hospital admission remains upheld.