Diagnosis: Headaches
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with a history of chronic migraines who presented to the emergency room (ER) with complaints of headaches for 1 month not relieved with usual abortive medications. She also had associated nausea and vomiting and came to the emergency room (ER) for abortive therapy. A computed tomography (CT) scan of the head showed no acute findings and was unchanged from prior CT scans. A magnetic resonance imaging (MRI) scan of the brain showed no acute infarction or intra parenchymal enhancement to suggest metastasis. MRI of the neck and head showed no significant stenosis. She had a sodium of 126.
She was admitted with a diagnosis of hyponatremia, acute on chronic and it was thought that she had Syndrome of Inappropriate Antidiuretic Hormone (Secretion) (SIADH). Labs were drawn and intravenous (IV) fluids were held. For chronic migraine, Topamax was continued and she was being monitored. Neurosurgery was consulted and she was seen by neurosurgery. It was felt that her meningioma was stable and no acute neurosurgical intervention was required. She was seen by neurology who stated that her headache severity had reduced from more than 10 to 3 after 2 rounds of migraine cocktail and dexamethasone.
By morning, the patient stated that her headache was about 4 out of 10 and she was feeling better. Her blood pressure was controlled, and she had a normal physical exam. The sodium had improved to 132 after fluids were held. She had received intravenous (IV) iron repletion and was to continue on oral medications. The rest of her exam was unremarkable. She was doing much better and did not have any additional headaches. She was evaluated by physical therapy and recommended for discharge home with outpatient physical therapy (PT). She was discharged in stable condition. At issue is the medical necessity of an inpatient stay.

Admission at an inpatient level of care was not medically necessary.
The patient presented with an intractable migraine and though she had stable neurological signs and no acute findings on imaging, she was noted to have hyponatremia. She was reviewed by neurosurgery and there was no need for any acute neurosurgical intervention. By the following morning, her headache and sodium had improved. She had no migraine related complications nor any seizures or complications related to hyponatremia. She was also reviewed by neurology and advised to continue Topamax and to arrange outpatient long term follow-up of her headaches. The remainder of her stay was uneventful.
Records show that the headaches improved within the observation period; she did not have persistent vomiting, she had no acute findings on computed tomography (CT) or magnetic resonance imaging (MRI) of the brain, and a normal neurologic examination and no seizures. As a result, the care could have been provided at a lower level.