Appeal type: Medical necessity
Decision: Upheld

Primary DX: Central Nervous System/Neuromuscular.
Primary TX: Inpatient Hospital.
Additional TX: Emergency Care/Emergency Room.

The patient has a past medical history of morbid obesity, recurrent syncope, chronic nausea and dizziness, migraines and thyroid cancer.  The patient presented to the emergency department following an episode blurred vision in the right eye, nausea and headache.  She ate a mint, took ibuprofen and an anti-emetic, but she was confused.  She couldn't recall her name.  Bystanders called 911 and she was transferred to the emergency room where stroke team responded.  On exam she was staring and crying.  Her blood pressure (BP) was 179/119 and other vital signs were stable.  Labs were stable except for a creatine kinase (CK) of 292 and a white blood cell (WBC) count of 3.28.  She underwent an urgent computed tomography (CT) head followed by computed tomography angiography (CTA) head and neck, which were unremarkable except for heterogenous right thyroid gland with substernal extension measuring 6.6 x 5.2 centimeter (cm) with leftward tracheal deviation.  The patient was admitted to inpatient level of care and the history and physical documented the patient's symptoms had resolved upon arrival to the emergency room.  The patient had a normal urinalysis.  She was treated with intravenous (IV) acetaminophen.  The patient was seen in consultation by stroke neurologist (while in the emergency department (ED) who recommended magnetic resonance imaging (MRI) of the brain and neuro checks.  The patient reportedly had similar symptoms in the last 3-4 months.  The patient was seen also in consultation with endocrinology because of the enlargement of the thyroid.  Thyroid function tests were normal and further outpatient follow up was recommended.  An MRI was not able to be completed because the patient had a panic attack and couldn't tolerate it despite dosing of anxiolytics.  Neurology felt the patient could have further outpatient evaluation as she had recently had an MRI in the last few months in the setting of similar symptoms.  The patient had no recurrent symptoms and her vital signs remained stable.  It was felt she likely had a complicated migraine.  She was discharged with further outpatient follow up.  At issue is the medical necessity of the inpatient level of care.  The health plan's determination of medical necessity is upheld in whole.  No, the inpatient stay is not medically necessary.  The patient had presented with atypical neurologic symptoms in the setting of known migraine and recurrent syncope, nausea and dizziness.  The patient's symptoms resolved by the time the patient was evaluated in the emergency department.  The BP was initially elevated but normalized in the emergency room.  The patient was not started on antiplatelet medication at the time of admission (which would be typical if concerned with transient ischemic attack (TIA).  The patient had normal labs and normal CTA of the head and neck.  There was an incidental finding of enlarged thyroid gland in the setting of previous history of thyroid cancer and the patient did have endocrinology consultation which was not urgent.  The patient was seen by neurology in the ED when evaluated with the stroke team and a nonurgent MRI was recommended.  The patient could not undergo MRI due to her anxiety and neurologist did not feel it was warranted during the admission due to high likelihood of complex migraine causing her symptoms.  The severity of illness and complexity of care were not at inpatient level of care.  In summary, the admission was not medically necessary at the inpatient level of care.