Diagnosis: hemicrania continua.
Treatment: inpatient admission.
The insurer is denied coverage for inpatient admission.
The denial is upheld.

This female patient has a history of migraines, hypertension, diabetes who presented to the Emergency Department for a headache that was progressively worsening. She had been seen at another facility and given medications, but had no relief. She was given pain medication, magnesium, and anti-emetics. She was admitted and received intravenous (IV) fluids. A neurology consult was called. It was determined she had hemicrania continua. She was started on IV Valproate and improved. She was then cleared for discharge for outpatient follow up.

According to current literature a patient may be admitted to inpatient services when there is evidence that the patient has an altered mental status that is severe or persistent, vomiting that is severe persistent, dehydration that cannot be corrected in a lower level or when there is documentation of severe new neurologic findings requiring inpatient services. The documentation does detail this patient presented with complaints of 3 months of left-sided headaches radiating with associated symptoms. The examination revealed the patient was alert and oriented. There were no vision changes and no difficulty with walking or talking. She underwent imaging revealing no acute findings and was given medication without improvement. The patient was admitted and was treated with further IV fluids and medications. While it is noted this patient initially presented with ongoing complaints of a headache, the documentation does not detail this patient was appropriate for admission to inpatient services. There was no evidence of significant hemodynamic instability, dehydration that was severe or persistent, vomiting that was severe or persistent or altered mental status that was severe or persistent. The documentation indicated the patient was given IV Toradol and Reglan. It does not appear she exhausted all outpatient management options for her appropriate care in a lower level prior to admission into inpatient services. Therefore, given the patient could be treated at a lower level, the requested inpatient was not medically necessary and the prior determination remains upheld.

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

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