Appeal type: Medical necessity
Decision: Upheld

Neurological
Inpatient hospital stay

The patient has a past medical history significant for diabetes mellitus and hypertension. The patient presented to the emergency department with complaints of facial weakness and numbness that started 8 hours before presentation. The patient also complained of pain in the left ear and droop on the left side of the face upon awakening in the morning. The patient stated that one day before the day of admission the patient noticed some drooling on the left side of mouth. At the time of admission, the patient denied headaches, dysarthria, chest pain, palpitations, abdominal pain, seizures, loss of consciousness, dysphagia.
In the emergency department, the patient was found to be hypertensive with left-sided facial weakness. A left facial droop was associated with difficulty closing the eye and also elevating the eyebrow.  Hearing was intact. The palate was symmetrically elevated. The muscle strength was intact on the left side of the face and in both extremities. The patient was admitted to the hospital to rule out acute cerebrovascular accident (CVA). At the same time, the most likely diagnosis at the time of admission was Bell's palsy. Therefore the patient was started on a 10-day course of Prednisone as well as the application of eye patch. During the hospital stay the patient was started on Acyclovir. Since the patient remained in a stable clinical condition, the patient was discharged home.
The health plan's determination of medical necessity is upheld in whole. The requested health service/treatment of inpatient stay was not medically necessary for this patient.
The patient's presentation was most likely related to Bell's palsy  based on the patient's history and the results of the physical exam; not an acute stroke. Bell's palsy is a condition that is usually treated as an outpatient. The neurologic exam and the results of the diagnostic studies demonstrated that Bell's palsy was the most probable diagnosis. The patient did not require any procedures or treatment necessitating admission at the acute inpatient level of care. The main principles of the treatment of Bell's palsy are the protection of the cornea and treatment with corticosteroids. Those treatments do not require admission at the acute inpatient level of care.
Considering the fact that a definitive diagnosis was in question at the time of the initial presentation, it was reasonable to admit the patient for a short period at a lower level of care and perform imaging studies as well as to continue clinical monitoring. According to the Milliman Care Guidelines (MCG) Health General Recovery Care 23rd Edition Neurology GRG criteria, this patient did not meet the criteria since there was no evidence of central nervous system (CNS) infection, vasculitis, cerebral aneurysm, myasthenia gravis, acute exacerbation of multiple sclerosis, severe myopathy, or any other neurologic conditions requiring admission at the acute inpatient level of care. Even though the patient had a new onset of neurologic symptoms, those symptoms were related to the distribution of one particular nerve and were unlikely to represent a serious condition requiring admission at the acute inpatient level of care.
Neither the severity of the patient's condition not the complexity of the services provided justified admission at the acute inpatient level of care.