Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld in whole. 

The patient is a female with a past medical history significant for depression, anxiety, obesity, hypertension, and diabetes mellitus who presented to the emergency department with complaints of bilateral lower extremity weakness, more pronounced on the left side and associated with numbness in the legs. The patient noticed bilateral leg weakness and swelling approximately 2-3 weeks before the presentation.
She previously visited the emergency department where she received treatment with Toradol and Gabapentin for possible neuropathy. She also received Labetalol because her blood pressure was elevated.
She came back to the emergency department with new onset of left leg numbness, which was associated with muscle cramping in the calf.
The patient endorsed having some chills and an increased frequency of urination.
At the same time, the patient denied fever, shortness of breath, chest pain, abdominal pain, cough, palpitations, dizziness, dysuria, diarrhea or constipation, nausea, or vomiting.

Computed tomography (CT) scan of the head showed small vessel changes in both cerebral hemispheres, slightly advanced for age. There was no evidence of acute bleed or infarct. Tissue plasminogen activator (tPA) was not administered.
Subsequently, a magnetic resonance imaging (MRI) of the brain was performed and was negative for acute infarct but was suspicious for a cystic lesion within the right cavernous sinus. 
The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld in whole.

The inpatient stay was not medically necessary for this patient.
At the time of admission, it was suspected that the patient could have transient ischemic attack (TIA) or cerebrovascular accident (CVA). However, at the time of admission and during the entire hospital stay, the patient had no signs of hemodynamic instability, persistent or recurrent focal neurologic signs. There was no evidence that the patient, in fact, had an acute stroke. Her symptoms were not associated with altered mental status, cardiac arrhythmias of immediate concern, or clinically significant cardiac disorders. There was no evidence that the patient had severe hypertension requiring invasive blood pressure monitoring or intravenous infusions of medications to get the blood pressure under control.
Even though this patient had a severe peripheral arterial disease, there was no mention that the patient had acute ischemia in the limb requiring any intervention or surgery during this hospital stay.
This patient also did not need any procedures for the evaluation of the thyroid gland nodule that would require admission at the acute inpatient level of care.
Taking into consideration all these facts, there is no evidence that either the severity of the patient's condition or the complexity of the services provided rose to the acute inpatient level of care.
There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care status.