External Appeals Searchable Archive

Database of closed NYS External Appeals that provides case summaries and appeal outcomes

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Showing 1 to 10 of 11075
Summary References
Ears/ Nose/ Throat
Inpatient Hospital
Empire Healthchoice Assurance Inc.
Upheld
Medical necessity
Male
30-39
2021
IPRO
202102-134717
202102-134717

  • Summary:

    Diagnosis: postoperative bleeding Treatment: inpatient admission The insurer is denied coverage for inpatient admission The denial is upheld. This male patient has a history of ulcerative colitis. The patient presented to the Emergency Room (ER) with complaints of bleeding after having a tonsillectomy. The patient had a tonsillectomy on the day prior to arrival (PTA). The patient stated that he was taking only liquids and soft food by mouth (PO). The patient was hemodynamically stable and communicating through writing. The physical examination of the oral cavity revealed multiple raw and erythematous areas throughout the tonsil. There was no active bleeding. The patient was initially kept nothing-by-mouth (NPO) and intravenous (IV) fluids were given. The patient was admitted with postoperative bleeding. Otolaryngology consulted over the case for difficulty swallowing, and they recommended trying a clear liquid diet after 4 hours of NPO. The patient was monitored and there was no more active bleeding during the admission. The patient was discharged after a period of medical stability. At that time, the patient was ambulating and tolerating a clear liquid diet. The patient's pain was well-controlled. Postoperative tonsillectomy bleeding tends to occur in the first few days post-surgery or at approximately 10 days post-surgery (when clots tend to come off or dissolve). This patient had a tonsil postoperative bleed on postoperative day #1 (POD#1). The amount of blood noted over the two hours of bleeding appeared substantial (quoted as filling two small bags) but the bleeding stopped on presentation to the ER. Additionally, when the blood clot was removed from the tonsil, there was no active bleeding and silver nitrate was applied. The notes also described this patient's hospital course overnight as was "observed overnight...no further episodes of bleeding...stable...ambulating... tolerating a clear liquid diet and pain was controlled". The physical exam next day showed "breathing comfortably on room air...not In acute distress (NAD)]...no stridor...no blood noted in saliva....no hematoma". The notes of appeal by the hospital also note tachycardia but this is often seen when a patient is or was bleeding and is understandably anxious. The patient's normal hemoglobin and hematocrit, and healthy young status are indicative that this patient was not in distress and as the hospital notes stated the patient was hemodynamically stable. Typical guidelines/medical necessity/criteria for admission versus observation appear to be fulfilled for observation/ambulatory admission since the records show that the patient was hemodynamically stable, afebrile, controlled pain, and the patient ambulated, was not actively bleeding, and was tolerating oral intake. 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.

  • Reference:

    1) "Tonsillectomy in adults" quoted from the UPTODATE WEBSITE. Author: Marc J Gibber, MD; Section Editor: Marvin P Fried, MD, FACS; Deputy Editor: Wenliang Chen, MD, PhD. Literature review current through: Feb 2021. This topic last updated: Sep 29, 2020. 2) Ear Nose Throat J. 2021 Mar 9;145561321999594. doi: 10.1177/0145561321999594. Online ahead of print. "Management of Recurrent and Delayed Post-Tonsillectomy and Adenoidectomy Hemorrhage in Children." Phylannie K F Cheung 1, Joanna Walton 1, Megan L Hobson 1, Piera Taylor 1, Michael Chin 1, Simone Boardman 1, Alan T L Cheng 1 2, Catherine S Birman 1 2 3 3) Ann Otol Rhinol Laryngol. 2021 Jan 13;3489420987438. doi: 10.1177/0003489420987438. "Post-Tonsillectomy Bleeding: A National Perspective." Nehal Dhaduk 1, Ashley Rodgers 1, Aparna Govindan 2, Evelyne Kalyoussef 1
Central Nervous System/ Neuromuscular Disorder
Inpatient Hospital
Empire BlueCross BlueShield HealthPlus
Upheld
Medical necessity
Female
50-59
2021
IPRO
202102-134723
202102-134723

  • Summary:

    Diagnosis: Vertigo Treatment: Inpatient admission The insurer has denied coverage for inpatient admission. The denial is upheld. This female patient has a history of hypertension who presented to the Emergency Department (ED) with complaints of vertigo times 6 hours. The patient reported she felt like the room was spinning, and it was worse when sitting up and standing. The patient denied any nausea or vomiting. The patient's vital signs were the following: blood pressure of 131/76, pulse of 85, temperature of 97.8 degrees Fahrenheit, respiratory rate of 20 and oxygen saturation of 100%. The patient's electrocardiogram (EKG) indicated normal sinus rhythm. The patient's lab work was significant for the following: creatine phosphokinase 258, potassium 3.1, lactic acid 3.4 and glucose 174. The patient's magnetic resonance imaging (MRI) of the brain did not show an infarct or hemorrhage. The treatment plan in the ED included intravenous (IV) fluids, Benadryl, metoclopramide and meclizine. The patient's symptoms did not improve. Neurology was consulted, and the recommendation was to continue with metoclopramide and meclizine and to start lorazepam. The patient experienced some relief. The patient was admitted to the Medicine service for further evaluation. The patient's symptoms improved with Ativan, and she was also given potassium due to a low potassium lab level. There was an incidental finding of a possible 1 millimeter (mm) right A1/A2 junction tiny aneurysm, and the recommendation was to consider getting a magnetic resonance angiogram (MRA) as an outpatient for further evaluation. The patient was medically cleared for discharge with outpatient instructions to follow up with her primary care physician. Based on the review of the medical record and literature, inpatient hospital admission was not medically necessary for this patient. The patient was stable at the time of admission. The patient was not noted to be in distress and she did not have severe neurological findings to support the need for inpatient admission. The patient could have undergone treatment under observation status. The health plan 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.

  • Reference:

    1) MCG Health 24th ed. (2020) Dizziness, ORG: M-152 (ISC) 2) Pfieffer, M. L., Anthamatten, A., & Glassford, M. (2019). Assessment and treatment of dizziness and vertigo. The Nurse Practitioner, 44(10), 29-36.
Genetic Diseases, Central Nervous System/ Neuromuscular Disorder
Inpatient Hospital
Metroplus Health Plan
Upheld
Medical necessity
Male
10-19
2021
MCMC, LLC
202102-134924
202102-134924

  • Summary:

    Diagnosis: Dandy-Walker syndrome, developmental delay, ventricular shunt, mental retardation, and seizures Treatment: Inpatient admission The insurer denied the inpatient admission. The denial is upheld. This male has conditions including Dandy-Walker syndrome, developmental delay, ventricular shunt, mental retardation, and seizures. The patient presented with his mother to the emergency department (ED) because the mother was unable to care for him after breaking her leg. He had no medical complaints. The patient's vital signs (VS) were as follows: temperature 97.7, pulse 93, respiratory rate 18, nlood pressure 124/71. and oxygen saturation 97%. Exam was remarkable for nonverbal and does not follow commands. Complete blood count (CBC) was unremarkable. Comprehensive metabolic panel (CMP) was remarkable for sodium (Na) 147 and aspartae aminotransferase (AST) 16. The patient was admitted for social disposition. The maximum temperature (Tmax) was 101.5, there was no acute disease (NAD), and no leukocytosis. Plan was for blood cultures. Antibiotics were put on hold. No, the proposed treatment was not medically necessary. Medically necessary services are those which are: safe effective generally accepted national standard of medical practice not provided primarily for convenience of the patient or the practitioner the least intensive and/or most appropriate alternatives among diagnostic and treatment option. The requested inpatient admission was not medically necessary because it was not in accordance with generally accepted national standard of medical practice for this patient's scenario. Vital signs were stable (VSS); the patient was afebrile. Chest x-ray (CXR) showed no acute disease (NAD). Blood cultures were negative. Urine analysis (U/A) was negative. Coronavirus (COVID) was negative. The patient remained hemodynamically stable and afebrile though hospital stay. Discharge was delayed pending discharge planning. The patient was discharged. This is a patient with chronic conditions including Dandy-Walker syndrome, developmental delay, and mental retardation. The patient was admitted for social disposition after his mother was unable to care for him. He was hemodynamically stable and in no acute distress. Labs were unremarkable for acute findings that required an inpatient level of care. There were no acute conditions identified. Plan of care was placement. The patient had one time temperature spike with negative work up. Otherwise, his hospital stay was unremarkable. He was not receiving interventions at an acute inpatient level of care. Discharge was delayed pending placement. He was discharged after being placed in a nursing home. Inpatient admission was not medically necessary for this scenario.

  • Reference:

    Not applicable. The decision is based on clinical experience and judgment, as well as review of the medical records.
Dental Problems
Dental/ Orthodontic Procedure
Fidelis Care New York
Upheld
Medical necessity
Male
10-19
2021
MCMC, LLC
202102-134957
202102-134957

  • Summary:

    Diagnosis: Class III skeletal relationship Treatment: D8080- Braces, Pre-service The insurer denied the D8080- Braces, Pre-service. The denial is upheld. The patient is a male. The request is for dental benefits for Orthodontic treatment (Braces). The Dental Clinical summary states---Patient presents with a class III skeletal relationship--hypoplastic maxilla, mild upper and lower teeth spacing, undersized upper incisors, anterior crossbite with gingival attachment loss. No, the proposed treatment of orthodontic therapy is not medically necessary. Although the patient does have a class III skeletal relationship, the protrusion of the lower jaw is not significant enough to cause the upper teeth to fall behind the lower teeth. This produces more of an edge to edge bite--with only the upper right lateral incisor falling ever so slightly behind the corresponding lower tooth. A significant crossbite is not supported by the photos submitted. No substantial chewing or speech function is compromised as a result of the positioning of the patient's teeth. The information submitted does not show a level of severe malocclusion and therefore would not warrant comprehensive orthodontic treatment.

  • Reference:

    1) Correction of Crossbite by B D Lee ( Dental Clinics of North America, 1978) 2) Evidenced Based Orthodontics--2nd ed--by Greg J. Huang, Stephen Richmond, Katherine W. L. Vig ( Wiley-2018)
Cardiac/ Circulatory Problems
Inpatient Hospital
Empire Healthchoice Assurance Inc.
Upheld
Medical necessity
Male
60-69
2021
IMEDECS
202102-135072
202102-135072

  • Summary:

    Diagnosis: Cardiac/Circulatory Problems. Treatment: Inpatient hospital The insurer denied inpatient hospital admission for medical necessity. The denial was upheld. The patient is a male who initially presented to an urgent care and was found to have hyperglycemia. He was sent to the hospital. His pertinent history included diabetes mellitus, renal cancer with metastases to the lungs and thoracic lymph nodes undergoing active chemotherapy and prednisone use, and chronic kidney disease. Upon arrival the patient was afebrile, hemodynamically stable, and without hypoxia. His initial examination documented the patient as alert and oriented. Serology was obtained and revealed a serum glucose of 257, Anion gap of 10, creatinine (Cr) was 1.6 (improved from baseline), white blood cell count (WBC) was 15.7, and lactic acid was 2.6. His electrocardiogram (EKG) revealed sinus bradycardia without acute ischemic changes or conduction abnormalities. Multiple tests and labs were done and pertinent for a negative troponin and clear chest radiography. Due to persistent asymptomatic sinus bradycardia of unknown etiology, the plan was to admit to telemetry overnight for further evaluation. His serum glucose returned at 257. Endocrinology consultation was obtained whom noted a heart rate of 64 and a morning fingerstick glucose of 69. They had an impression of steroid-induced hyperglycemia and recommended subcutaneous insulin. Recommendations were to hold metoprolol and continue telemetry. Cardiology consultation was obtained whom had an impression of sinus bradycardia possibly due to high dose steroids. The serum glucose remained in appropriate ranges. Treatment plan remained unchanged. The attending physician also noted serum glucose control and felt the patient was medically stable for discharge. At issue is the inpatient stay for medical necessity. The health plan's determination of medical necessity is upheld in whole. The requested health service/treatment of inpatient stay is not medically necessary for this patient. Based on the clinical documentation provided, evidence-based literature and standards of care, the inpatient level of care was not indicated as medically necessary for the entire admission. Savage et al. note that diabetic ketoacidosis is defined by the biochemical triad of ketonemia, hyperglycemia and acidemia. It remains a life-threatening condition despite improvements in diabetes care. In this particular case, these criteria were not met. Regarding the bradycardia, Semlka, et al. note that treatment of sick sinus syndrome includes removing extrinsic factors, when possible, and pacemaker placement. Pacemakers do not reduce mortality, but they can decrease symptoms and improve quality of life.[2] In this particular situation, expert consultation with a cardiologist was obtained whom had an impression of clinically insignificant sinus bradycardia. Thus, pacemaker implantation was not indicated. Therefore, the requested treatment of inpatient stay was not medically necessary.

  • Reference:

    1) Savage MW, Dhatariya KK, Kilvert A, Rayman G, Rees JA, Courtney CH, HiltonL, Dyer PH, Hamersley MS, Joint British Diabetes Societies. Joint British Diabetes Societies guideline for the management of diabetic ketoacidosis. Diabetic Medicine. 2011 May;28(5):508-15. 2) Semelka M, Gera J, Usman S. Sick sinus syndrome: a review. American family physician. 2013 May 15;87(10). 3) Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR, Goldschlager NF, Hamilton RM, Joglar JA, Kim RJ, Lee R. 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society. Circulation. 2019 Aug 20;140(8):e333-81.
Blood Disorder
Inpatient Hospital
Fidelis Care New York
Upheld
Medical necessity
Male
60-69
2021
IMEDECS
202102-135108
202102-135108

  • Summary:

    Diagnosis: Blood Disorder/Anemia Treatment: Inpatient Hospital The health plan denied the requested inpatient hospital stay due to the lack of medical necessity. The health plan's determination is upheld. The patient is a male with a medical history of hypertension, nephrotic syndrome, gout, and benign prostatic hyperplasia. He presented to the emergency department with hematochezia, constipation, dyschezia, fatigue, and unintentional weight loss of 18 pounds over 6 months. Vital signs were notable for tachycardia with heart rate of 117/minute. Physical examination was notable for soft, nontender, nondistended abdomen, and rectal exam negative for external hemorrhoids and melena. Labs showed low hemoglobin of 6.9 and a hematocrit of 22.9%, an elevated platelet count of 630, and an elevated neutrophil fraction of 85%. Stool was trace guaiac positive. A chest x-ray showed no acute cardiac or pulmonary pathology. He was transfused with two units of packed red blood cells. He was discharged with a plan for primary care, gastroenterology, and colorectal surgery follow-up. The health plan's determination of medical necessity is upheld, in whole. No, the medical necessity of the inpatient level of care is not supported. In this case, the patient presented with symptomatic anemia, concerning for gastrointestinal bleeding; however, there was no sustained tachycardia or hypotension, and no significant visible ongoing gastrointestinal bleeding. The patient had close monitoring, which was warranted as bleeding can be severe and sudden in onset [1-5]. His blood count responded to transfusion and remained stable. Esophagogastroduodenoscopy and colonoscopy were warranted and performed, with confirmation of rectal cancer as a cause for hematochezia and anemia [1-5]. All the measures that were undertaken, including monitoring, blood transfusion, labs, specialist consultations, imaging, esophagogastroduodenoscopy, and colonoscopy, could have been performed without the inpatient level of care, at the observation level of care [2-5].

  • Reference:

    1) Søreide K, Thorsen K, Harrison EM, et al. Perforated Peptic Ulcer. Lancet. 2015;386(10000):1288-1298. 2) Lanas A, Chan FKL. Peptic Ulcer Disease. Lancet. 2017 Aug 5;390(10094):613-624. 3) Saleem S, Thomas AL. Management of Upper Gastrointestinal Bleeding by an Internist. Cureus. 2018;10(6):e2878. Published 2018 Jun 25. 4) Kavitt RT, Lipowska AM, Anyane-Yeboa A, Gralnek IM. Diagnosis and Treatment of Peptic Ulcer Disease. Am J Med. 2019 Apr;132(4):447-456. 5) Jeong N, Kim KS, Jung YS, Kim T, Shin SM. Delayed Endoscopy is Associated with Increased Mortality in Upper Gastrointestinal Hemorrhage. Am J Emerg Med. 2019 Feb;37(2):277-280.
Central Nervous System/ Neuromuscular Disorder
Pharmacy/ Prescription Drugs
Fidelis Care New York
Overturned
Medical necessity
Female
60-69
2021
IPRO
202102-135169
202102-135169

  • Summary:

    Diagnosis: Bi-temporal epilepsy of unknown etiology. Treatment: The medication Pregabalin capsules, up to 800 mg [milligrams] daily. The insurer denied coverage for the medication Pregabalin capsules, up to 800 mg [milligrams] daily. The denial is overturned. This is a female patient with a past medical history of bi-temporal epilepsy of unknown etiology. The Letter of Medical Necessity states that the patient had been taking 300 milligrams (mg) of pregabalin twice a day for focal epilepsy. The patient experienced breakthrough seizures and her dose was increased to 300 mg in the morning and 400 mg in the evening. The patient had been seizure-free since that time without adverse effects. The patient previously tried and failed levetiracetam, lacosamide, oxcarbazepine, and eslicarbazepine at maximally tolerated doses. The provider noted that the patient should continue on the higher dose to maintain her current level of good seizure control. Based on the review of the medical record and literature, pregabalin capsules up to 800mg daily is considered medically necessary for this patient. Given multiple prior failed antiepileptic drugs, change to another agent once this patient's seizures are controlled, would risk breakthrough seizure and injury, or unwanted side-effects. Standard of care is to leave antiepileptic medications unchanged once seizures are controlled and side-effects are absent. Pregabalin is an adequate choice for focal seizures as is the case with this patient. The medication, Pregabalin capsules, up to 800 mg daily is considered medically necessary for this patient. The health plan did not act reasonably with sound medical judgment and in the best interest of the patient. The medical necessity for the medication Pregabalin capsules, up to 800 mg [milligrams] daily is substantiated. The insurer's denial should be overturned.

  • Reference:

    1) Cross, A.L. and Viswanath, O., 2020. Pregabalin. StatPearls [Internet]. 2) Morano, A., Palleria, C., Citraro, R., Nesci, V., De Caro, C., Giallonardo, A.T., De Sarro, G., Russo, E. and Di Bonaventura, C., 2019. Immediate and controlled-release pregabalin for the treatment of epilepsy. Expert review of neurotherapeutics, 19(12), pp.1167-1177.
Skin Disorders
Pharmacy/ Prescription Drugs
Aetna
Overturned
Medical necessity
Female
40-49
2021
MCMC, LLC
202102-135177
202102-135177

  • Summary:

    Diagnosis: Alopecia Areata Treatment: Xeljanz XR 10mg Tab, Pre-service The insurer denied the Xeljanz XR 10mg Tab, Pre-service. The denial is overturned. The patient is a female with severe alopecia areata and vitiligo. She has severe eye irritation from lack of eyelashes and eyebrows. She has failed topical, intralesional, and systemic steroids, as well as topical calcineurin inhibitors. She has been on tofacitinib ten milligrams (mg), twice daily, for six weeks and continues to lose hair. Yes, the proposed Xeljanz is medically necessary. The current literature reflects Xeljanz as being more effective than other treatments. Alopecia areata (AA) is a relatively common disease, but no satisfactory treatment has yet been developed. Recently, research progress has been made in the pathogenesis of alopecia areata, revealing that autoreactive cytotoxic T cells are important and that the Janus kinase (JAK) pathway is involved. Therefore, the potential of Janus kinase (JAK) inhibitors as therapeutic agents for alopecia areata is attracting attention. There have been a number of case reports and small clinical trials reporting promising outcomes of Janus kinase (JAK) inhibitors tofacitinib, ruxolitinib and baricitinib for alopecia areata. The majority of the literature to date is based on small volume data, with a lack of definitive evidence or guidelines. A retrospective study of 90 adults with severe alopecia areata (at least 40 percent scalp hair loss, alopecia totalis, or alopecia universalis) who had stable or worsening disease for at least six months and received oral tofacitinib (five to ten milligrams [mg] twice daily) for at least four months (with or without adjuvant prednisone) supports benefit. Of the 65 patients with a duration of the current disease episode of ten years or less, 77 percent had a clinical response (at least six percent improvement in the Severity of Alopecia Tool [SALT] score) and 58 percent achieved greater than 50 percent improvement in the Severity of Alopecia Tool (SALT) score over four to 18 months of treatment. Patients with a disease episode longer than ten years appeared less likely to respond to treatment; the clinical response rate in this population was 32 percent (eight of 25 patients). No serious adverse effects occurred during treatment. Therefore, given the above, Xeljanz is the best treatment option for this patient at this time. Treatment with Xeljanz is currently the best treatment option for this patient at this time. Given this patient's diagnosis and history, treatment with Xeljanz would be considered to be reasonable and consistent with the current standard of care in the dermatology community.

  • Reference:

    1) Craiglow BG, King BA. Killing two birds with one stone: oral tofacitinib reverses alopecia universalis in a patient with plaque psoriasis. J Invest Dermatol 2014; 134:2988. 2) Dhayalan A, King BA. Tofacitinib Citrate for the Treatment of Nail Dystrophy Associated With Alopecia Universalis. JAMA Dermatol 2016; 152:492. 3) https://www.uptodate.com/contents/alopecia-areata-management#references 4) Park H, Yu DA, Kwon O. Janus kinase inhibitors: An innovative treatment for alopecia areata. J Dermatol. 2019 Aug;46(8):724-730. doi: 10.1111/1346-8138.14986. Epub 2019 Jun 25. Review. PubMed PMID: 31237712. 5) Phan K, Sebaratnam DF. JAK inhibitors for alopecia areata: a systematic review and meta-analysis. J Eur Acad Dermatol Venereol. 2019 May;33(5):850-856. doi: 10.1111/jdv.15489. Epub 2019 Apr 10. PubMed PMID: 30762909. 6) Serdaroglu S, Engin B, Çelik U, Erkan E, Askin Ö, Oba Ç, Kutlubay Z. Clinical experiences on alopecia areata treatment with tofacitinib: A study of 63 patients. Dermatol Ther. 2019 May;32(3):e12844. doi: 10.1111/dth.12844. Epub 2019 Feb 7. PubMed PMID: 30693634.
Cardiac/ Circulatory Problems
Advanced Imaging Services (Including PET/ MRI/ CT)
Fidelis Care New York
Upheld
Medical necessity
Male
20-29
2021
MCMC, LLC
202102-135215
202102-135215

  • Summary:

    Diagnosis: Congenital total anomalous pulmonary venous return Treatment: 93303 Transthoracic Echocardiography (TTE), Pre-service The insurer denied the 93303 Transthoracic Echocardiography (TTE), Pre-service. The denial is upheld. The patient is a male with a history of congenital total anomalous pulmonary venous return status post (s/p) surgical correction, as well as obesity, sleep apnea and asthma. The patient was seen by a cardiologist and an echocardiogram was done. The patient was found to have calcified posterior mitral leaflet with trace mitral regurgitation. Due to the history of congenital heart disease, the patient was referred to an adult congenital heart disease specialist and a repeat echocardiogram was requested. Repeat study was denied, as there was documentation of a recent echocardiogram performed and no new symptoms or signs were reported. No, the proposed 93303 Transthoracic Echocardiography (TTE) is not medically necessary. The medical necessity of the proposed treatment is not established. As per the provided medical records, the patient had a documented echocardiographic study performed, with findings as documented in the report. There have been no new symptoms or change in clinical condition reported. There is no documentation that the recent echocardiogram was incomplete or of poor quality. Therefore the medical necessity of repeat echocardiogram could not be established.

  • Reference:

    1) Harrison's Principles of Internal Medicine, 20th Edition J. Larry Jameson, Anthony S. Fauci, Dennis L. Kasper, Stephen L. Hauser, Dan L. Longo, Joseph Loscalzo. 2) CURRENT Medical Diagnosis and Treatment 2019, 58th Edition (LANGE CURRENT Series) by Stephen J. McPhee and Maxine Papadakis 3) Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, Single Volume (Heart Disease (Braunwald) (Single Vol)) 11th Edition by Peter Libby MD, Robert O. Bonow MD, Douglas L. Mann MD FACC, and Douglas P. Zipes MD.
Genitourinary/ Kidney Disorder, Ears/ Nose/ Throat
Inpatient Hospital
Healthfirst Inc.
Upheld
Medical necessity
Female
50-59
2021
MCMC, LLC
202102-135428
202102-135428

  • Summary:

    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.

  • Reference:

    1) Malhotra A, Wu X, Gandhi D, Sanelli P. The Patient with Thunderclap Headache. Neuroimaging Clin N Am. 2018 Aug;28(3):335-351. 2) Molitch ME. Diagnosis and Treatment of Pituitary Adenomas: A Review. JAMA. 2017 Feb 7;317(5):516-524.