Diagnosis: Dizziness and impaired balance

Treatment inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This patient presented with dizziness. In the emergency department (ED), she had normal vital signs and her exam revealed nystagmus as well as positive Romberg sign. Head computed tomography (CT) was normal. Routine blood work was normal. In the ED, she could not ambulate due to severe dizziness. She was admitted to inpatient level of care for rule out stroke. Chest x-ray revealed a 1.5 cm (centimeters) pulmonary nodule which on subsequent CT chest that showed findings consistent with primary lung neoplasm or possibly metastatic disease. She continued to remain very dizzy and unable to progress with physical therapy (PT). Magnetic resonance imaging (MRI) of the Brain was negative for stroke. CT abdomen and pelvis did not reveal metastatic disease. She was noted to have some slow improvement in her symptoms.

Given that the patient had persistent dizziness and impaired balance in the ED that was concerning for a central cause, including possible acute stroke as well as a new neoplastic process based on suspicion of underlying new malignancy from chest x-ray, inpatient level of care was medically necessary.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for inpatient admission is overturned