Diagnosis: Intractable Headaches with Dizziness.
Treatment: Inpatient Hospital Admission.

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

This case involves a patient who presented to emergency department with a chief complaint of headache. The documentation indicated she does have a past medical history of hypertension and endorsed blurry vision. She indicated she was seen at a different facility a few days prior with a work-up including a computed tomography (CT) scan which was unremarkable. She was also seen in the office by her neurologist who sent her for a repeat CT scan as well as further laboratory studies. Upon physical examination there was no significant findings. The recommendation was made to treat the patient with Benadryl, Reglan, and fluids. Her CT scan of the head was unremarkable as well as x-rays. Labs were only significant for mild leukocytosis. The patient remained stable with a normal neurological examination. It was recommended she be admitted for further evaluation and treatment. The documentation indicated she was admitted and continued treatment with medication. She was treated with antibiotics and the following day she was discharged due to lack of further adverse events and improvement in pain and vision.

The patient presented with intractable headaches with dizziness, vertigo, and blurred vision. The neurologist ordered a CT of the head which was unremarkable as were spinal x-rays. The patient was treated for presumed sinusitis with antibiotics and was treated for her headaches with several agents in the hospital. There was no evidence for stroke, hemorrhage, or aneurysm. The care provided, including diagnostic imaging, specialty consultation and medical management could have been provided in the emergency department (ED) or at an observation level of care. The care provided did not warrant inpatient admission. Therefore, the health plan acted reasonably with sound medical judgment 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.