Diagnosis: Incontinence, headache, and vertigo
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female with diabetes, hypertension, HIV (human immunodeficiency virus) and pituitary adenoma. She presented to the emergency ward with the complaint of incontinence, headache, and vertigo for two days.

At presentation, the patient had a non-focal neurological examination and negative CT (computed tomography) brain.

No, the inpatient admission was not medically necessary.

The patient presented with a two-day history of headache. She had a normal examination, and CT (computed tomography) brain did not demonstrate any acute or concerning findings. Based on the documented presentation, there were no concerning features (e.g. thunderclap headache, focal deficits) to support intracranial pathology requiring inpatient evaluation, monitoring or treatment. The diagnostic studies, monitoring, treatment and clinical evaluation could have been safely and effectively completed at a lower level of care.