Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Multiple Sclerosis.	

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient presented to the hospital with a history of multiple sclerosis (MS), hypertension, polycystic ovary syndrome, asthma, morbid obesity, and hernia repair.  The patient complained of pain/pressure behind the left eye that had been ongoing for 2 days.  There was associated numbness and paresthesia of the left upper and lower extremity with some weakness.  The patient described feelings of electrical shock down the arm frequently.  The patient had dizziness and lightheadedness.  The patient endorsed headache and described the symptoms as being similar to multiple sclerosis flare-ups in the past.  Vital signs noted temperature of 99.0 Fahrenheit, heart rate of 67, respirations of 18, blood pressure of 114/72, and oxygen saturation of 99% on room air.  Due to persistent symptoms, the patient was admitted for possible multiple sclerosis exacerbation.  A computed tomography (CT) of the head noted no acute pathology.  There was a plan for magnetic resonance imaging of the brain and cervical spine with a neurology consult.  Magnetic resonance imaging (MRI) of the brain revealed fluid-attenuated inversion recovery (FLAIR) hyperintensities in the right frontal, right corona radiates, left parietal area, and left parietal region compatible with multiple sclerosis.  Neurology suspected decompensation of previous multiple sclerosis or clinically isolated syndrome.  The patient had improvement of symptoms.  The patient was deemed appropriate for discharge with outpatient follow-up.

It was stated that the inpatient was not medically necessary.  The patient's care could have been managed at a lower level of care.  The documentation did not identify that the patient's condition did not get better or that the patient needed to stay in the hospital.  The patient could have been placed in observation for monitoring, and evaluation, and treated symptomatically while awaiting test results.  Consultation with other professionals could have been completed in observation.  There was no hemodynamic, pulmonary, neurological, or metabolic reason for the acute level of care.  There were no positive tests or other findings after evaluation by the physician that would have required an acute level of care.

Per the cited references, admission to the hospital is indicated for patients with multiple sclerosis when there is acute deterioration requiring inpatient treatment with parenteral medication or plasmapheresis, when there is severe pain that is insufficiently responsive to nonpharmacological and nonopioid pharmacological analgesics, when there is respiratory insufficiency, when there is inadequate airway protection, or when there is a weakness that is progressive or severe.  In this case, the patient presented to the hospital.  There was concern for multiple sclerosis flare.  It was argued that the inpatient was medically necessary.  However, the documentation did not detail the need for parenteral medication to address acute deterioration of multiple sclerosis, severe pain that was insufficiently responsive to nonpharmacological and nonopioid pharmacological analgesics, there is respiratory insufficiency, but there was inadequate airway protection, or that there was weakness that was progressive or severe.  Thus, the patient's care could have been completed at a lower level such as observation.  As such, the healthcare plan acted reasonably, with sound medical judgment, and in the patient's best interest.  The denial of coverage for an inpatient admission is upheld as not medically necessary.

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

The medical necessity for an inpatient admission is not substantiated.