Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Altered Mental Status

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld.

The patient presented to the hospital with a history of anemia, alcohol use disorder, chronic skin rash, and hypertension.  Per emergency medical services, the patient's blood pressure was 80/60.  The patient was given 1 liter (L) of normal saline and blood pressure increased to 126/93.  The patient presented to the emergency department with altered mental status and hypotension.  The husband reported that the patient was acting abnormal, would not get out of the chair, and was slurring their speech.  The patient's blood pressure improved with fluids.  However, the patient continued to have dysarthric speech and was not responding to questions.  Stroke code was called.  Emergency department vital signs noted a blood pressure of 99/61, temperature of 36.1 (degrees) Celsius (C), pulse of 80, respirations of 18, and oxygen saturation of 97% (percent) on room air.  The patient was ill appearing.  The pupils were small but reactive to light.  The patient's right elbow appeared misaligned.  There was an old well-healed surgical scar present.  Movement of the right elbow caused the patient pain.  There was a questionable facial droop.  There was concern for acute cerebrovascular accident versus transient ischemic attack.  There was also concern for altered mental status related to hypotension, myocardial infarction, hypoglycemia, or other metabolic derangement.  The presentation was most concerning for cerebrovascular accident.  Electrocardiogram was without evidence of ST elevated myocardial infarction or ischemia.  The patient was not hypoglycemic on fingerstick blood sugar check.  There was a plan to work-up the patient for acute cerebrovascular accident/transient ischemic attack.  A nursing note indicated that the patient was alert and oriented x(times)3 when being transported to have a computed tomography (CT) completed but did not know why they were in the hospital.  A CT of the head noted no indirect evidence for acute ischemia.  CT angiogram of the head and neck noted no hemodynamically significant stenosis or occlusion of the cervical spine arterial vessels.

Per the Milliman Care Guidelines (MCG) guidelines, hospital admission may be indicated for patients suspected of stroke when there is clinical need for inpatient care monitoring as indicated by hemodynamic instability such as hypotension that persists despite appropriate treatment or for severe hypotension with lactate of 2.0 or more secondary to hypotension, when there are cardiac arrhythmias of immediate concern, when a clinically significant cardiac or vascular disorder is identified that requires inpatient care, when there are respiratory abnormalities, when prolonged cardiac telemetry monitoring is needed, or when thrombolysis is performed or planned.  In this case, the patient presented to the hospital with hypotension, altered mental status, and reported episode of passing out.  The patient had initially responded to 1 L of normal saline.  There was concern for cerebrovascular accident.  The patient was admitted to the hospital for further work-up.  However, the documentation did not support that the patient had hemodynamic instability that persisted despite appropriate treatment.  

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 an inpatient emergency admission is not substantiated.