Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lightheadedness.
Treatment: Inpatient admission.

The insurer denied the inpatient admission.  The denial is upheld.

The patient is a woman. She presented to the emergency department as a code stroke. Her relevant comorbidities and risk factors include a history of smoking.

The patient subjectively reported lightheadedness and an inability to move, objectively reported as demonstrating nystagmus, a left facial droop, and a disconjugate gaze that self-resolved. She was admitted to the hospital for a stroke workup.  CT (computed tomography) head demonstrated no intracranial hemorrhage or acute infarct, and a stenosis of the right M2 (insular segment, middle cerebral artery) and M3 (opercular segments, middle cerebral artery) segments of the middle cerebral artery.  MRI (magnetic resonance imaging) demonstrated no vascular abnormalities. Echocardiogram was unremarkable.  Carotid duplex scan demonstrated no hemodynamically significant stenoses.  EKG (electrocardiogram) showed a normal sinus rhythm.  The patient was hemodynamically and clinically stable throughout her stay in the hospital and was discharged.

The health plan denied coverage for the inpatient stay with the contention that the care could have been safely executed without formal admission and completed in the emergency department or an observation unit.  The treating provider's reasoning for the appeal was the acuity of the presenting illness, the inability of the patient to adhere to the elements of the necessary workup as an outpatient and the concern that the patient would be lost to follow-up due to factors such as comorbid drug abuse.

No, the Inpatient admission was not medically necessary.

The patient did not experience a stroke. An MRI (magnetic resonance imaging) and non-invasive angiography (MRA [magnetic resonance angiography], CT A [Computed Tomographic Angiography], or ultrasound) could be performed in the emergency department or from an observation unit. This can demonstrate cerebrovascular stability and obviate the need for formal admission. Based on this, care could have been provided in a lower acuity setting.

With respect to the contention that the patient was better served by admission due to the possibility of a loss to follow-up, it is not role of the hospital to predict how patients may or may not engage with their care and preempt them based on factors such as comorbid substance abuse. It is the role of the hospital to provide care in an acute and timely fashion and afford patients every opportunity to access the complete spectrum of post-admission care, such that their health and well-being are served to the fullest extent.  By the hospital or the providers applying a prejudicial judgment of the patient's ability to access care based on a urine drug screen, the hospital strayed beyond its mandate.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.

The health plan allowed for coverage consistent with standard of care that would assure the patient the highest quality of care necessary for their condition as demonstrated by the investigations and assessments reported in the medical record.