Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hemiparesis

Treatment: Inpatient admission

The insurer denied the inpatient admission. 

The denial was overturned.  

This is a male patient with a medical history of a right hemispheric arteriovenous malformation (AVM) rupture, status post clipping, subsequent epilepsy, complicated by re-rupture and followed with partial embolization.  The patient underwent a staged embolization procedure with the last intervention in 11 days prior.  Postoperatively, the patient had numbness and weakness on his left side.  The patient presented to the Emergency Department (ED) with complaints of persistent numbness, leg weakness, arm weakness, and difficulty ambulating.  The patient had a facial droop, a downward arm drift, and a weak grip.  The patient's National Institutes of Health Stroke Scale (NIHSS) score was 4.  The physical examination of the patient revealed a cranial nerve deficit and a coordination abnormality.  There was decreased sensation intact to light touch (SILT) in the right upper and right lower extremity.  The patient was followed by neurology and sent in for possible acute rehabilitation.  The patient was to be admitted for hemiparesis, unspecified hemiparesis etiology, unspecified laterality.  The patient was admitted for physical therapy evaluation and acute rehabilitation placement.  The patient's computed tomography (CT) scan of the head revealed streak artifact from embolization coils with no evidence of acute lobar infarction, hemorrhage, or extra-axial collection.  The patient was evaluated by Physical Therapy (PT) and Occupational Therapy (OT), and it was recommended that the patient undergo acute rehabilitation.  The patient was discharged to a rehabilitation facility.

The current literature indicates that a patient may be admitted when there is evidence of a new neurologic symptom such as recurrent seizure, increased intracranial pressure, new focal neurologic deficits, altered mental status that is severe/persistent, or there is evidence of hemodynamic instability.  Within the documentation it was noted that this patient presented with visual changes and left-sided weakness and numbness.  The submitted documentation also indicated the high level of concern for this patient's high risk for catastrophic neurologic deficits should the patient bleed.  The patient's previous coils made imaging more challenging as a source of confirming a new stroke.  This patient's clinical state in this case would be most reliable means to assess for new stroke. 

According to the guidelines provided by the InterQual 2019, the acuity of this case warrants inpatient admission.  This patient presented with clinical findings suspicious for a new stroke, especially in the context of his complicated medical history.  Upon arrival to the hospital, the patient was quickly assessed for potential stroke intervention.  Given the ongoing physical deficits, it was appropriate to admit and observe the patient and start acute rehabilitation measures.  It would have been unsafe to discharge the patient.  Thus, inpatient hospital stay was medically necessary for this patient.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for the inpatient hospital is substantiated.  The insurer's denial should be overturned.