Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Altered mental status, body-wise tingling, and numbness
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.	
The denial is upheld.

The patient presented to the emergency department with complaints of whole-body numbness and tingling, most intense in the bilateral hands. The numbness and tingling began while riding in a car with her husband to go to a movie. There was no obvious trigger. The patient complained of being under stress. The patient had a history of hypertension, diabetes mellitus, and past alcohol use, but had no seizure history. The examination on presentation revealed evidence of anxiety on psychiatric examination, no nystagmus, no midline spinal tenderness, and normal general revealed her to be in acute distress with normal appearance. The patient had a normal head, eyes, ears, nose, and throat (HEENT), neck, cardiovascular, pulmonary, abdominal, musculoskeletal, skin, mental status, cranial nerve, sensory, motor, coordination, and gait examinations. The patient's diagnoses included altered mental status, near syncope, paresthesia, lactic acidosis and possible seizure. The laboratory testing revealed a lactic acidosis and low MCV (mean corpuscular volume). The chest x-ray was normal. The head computed tomography (CT) scan was negative. The CT angiogram of the head and neck were both negative. The patient was admitted to telemetry. A neurology consultation was planned. Magnetic resonance imaging (MRI) of the cervical spine was performed and was interpreted as revealing a cervical five through six (C5-6) posterior annular fissures, with a tiny central protrusion, without spinal canal stenosis, and without foraminal stenosis. A right upper quadrant ultrasound performed revealed hepatic steatosis. The patient was discharged, with plans for outpatient referrals to neurology and neurosurgery. 

The patient presented with diffuse sensory disturbances. The history and diagnosis indicate altered mental status, but there is no evidence of any alterations in consciousness at any time period. The neurological examination as documented on presentation was normal. However, acute brain and spinal cord pathology needed exclusion. The patient underwent a stroke evaluation that was negative. Acute spinal cord pathology can be ruled out with a cervical spine CT (computed tomography) scan (to rule out any acute external cord compression) and an MRI (Magnetic resonance imaging) to detect intrinsic spinal cord pathology. The patient had no other neurological deficit. The patient had a lactic acidosis without evidence in the other signs of sepsis and did not require any urgent evaluation for sepsis. The reduced MCV (mean corpuscular volume) was an incidental finding that could be further evaluated as an outpatient. The cervical spine MRI (Magnetic resonance imaging) could be performed in the emergency department setting or while under observation, with the patient discharged once acute pathology was ruled out. Otherwise, the patient had improved, and there is no evidence of any impending recurrence of symptoms or other neurological decline. There is no evidence of a need for any neurological checks. There is no evidence of any cardiac pathology to require cardiac monitoring. There is no evidence of any need for pulmonary or hemodynamic monitoring. The patient had a single event of whole-body numbness and tingling that resolved, and once spinal cord pathology was ruled out, there was no need for acute inpatient hospitalization. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is not substantiated.