Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left-handed numbness and tingling

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

According to the documentation submitted, this is an adult with a history of asthma, hypertension, coronary artery disease (CAD), bipolar disorder, bone tumor, intravenous drug use (IVDA), and tobacco abuse. The patient presented to the emergency room (ER) with complaints of right arm numbness and tingling. The patient was given 1 gram (g) of IV magnesium sulfate. A chest x-ray (CXR) and imaging of the head revealed no significant findings. Neurology recommended magnetic resonance imaging (MRI) of the cervical spine with gadolinium and an electromyogram (EMG) nerve conduction study for upper limbs on an outpatient basis. The patient was discharged. 

The insurer has denied coverage for the inpatient as not medically necessary. In a Final Adverse Determination, they stated that the patient presented to the ER with complaints of tingling and weakness on the right side. The patient was not unstable. There were no unstable vital signs that did not improve or other findings warranting an inpatient admission. The requested admission is denied based on Milliman Care Guidelines 26th Edition using the guideline of Neurology GRG. 

In an appeal letter they stated that the patient presented to the ER with complaints of right-handed numbness and tingling for one day. Imaging of the right arm and wrist revealed no significant findings. The patient was admitted with right arm numbness. The physician was concerned for possible neuropathy, vasculitis, or malignancy. The inpatient admission was warranted for this patient who needed a neurological examination. The requested admission was warranted based on Milliman Care Guidelines using the guideline of Neurology GRG. 

Based on the records provided for review the patient presented with right hand numb/tingling. Vital signs were unremarkable. Exam shows decreased sensation to right arm, impaired wrist extension, and decreased grip strength. Computed tomography of head, and EKG with no abnormalities. The patient was stable and could have been treated a lower level of care. In conclusion, the inpatient admission was not medically necessary, and his care could have been handled at the observation level of care.

"The painful tingling arm is a common presenting complaint for the musculoskeletal physician. The differential diagnosis for upper-extremity pain associated with paresthesias will be the focus of this review. Symptoms are often neurologic in etiology, originating from the spinal cord, nerve root(s), brachial plexus, or peripheral nerve(s). Localizing the pathology starts with a comprehensive understanding of neuromuscular anatomy. It also is imperative to understand the function of these respective structures. The differential diagnosis can be narrowed with a thorough history, including an assessment of sport-specific risk factors, along with a comprehensive physical examination and functional assessment. It is important to determine the sensory distribution of the patient's symptoms. If weakness also is present, the affected muscles must be identified. While the diagnosis can often be made clinically, electrodiagnostics, magnetic resonance imaging, and ultrasound can be used as needed for confirmation and more specific localization. Non-neurologic structures also may be causative or contributory to the patient's symptoms and also should be considered."

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.