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.

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.