Appeal type: Medical necessity
Decision: Upheld

Central Nervous System/Neuromuscular Disorder - Other
Inpatient Hospital

The patient is a female with a history of type 2 diabetes, hypertension (HTN), hyperlipidemia (HLD), and gastroesophageal reflux disease (GERD), who presented to the emergency room (ER) for vertigo for 2 days. She had taken Meclizine at home without relief. The neuro exam was normal. Her gait was slightly unsteady with a wide base.
The patient was admitted for vertigo and a possible cerebrovascular accident (CVA). The stroke neurology team was consulted. Orthostatics were negative. After a magnetic resonance imaging (MRI) of the brain, it was determined that the patient did not have an acute stroke and that the symptoms were likely from benign positional vertigo.
The patient's initial vitals included a blood pressure (BP) of 119/72 millimeters of mercury (mmHg), with a heart rate (HR) of 60 beats per minute (bpm), a temperature of 36.7C., an oxygen saturation of 99% on room air, and a respiratory rate (RR) of 17/minute. There were no significant lab abnormalities. Imaging was significant for an outpatient computed tomography (CT) of the brain which demonstrated a left midbrain infarct, a chest x-ray which demonstrated degenerative changes of the spine, a CT of the head with contrast which did not demonstrate significant stenosis, a computed tomography angiography (CTA) of the neck which demonstrated degenerative disc disease, worse at C5-C6 and no significant stenosis, an MRI of the brain which demonstrated chronic small vessel ischemic changes in the frontoparietal white matter and no acute CVA or hemorrhage, and a transthoracic echocardiogram (TTE) which demonstrated an ejection fraction (EF) of 60-65% and mild tricuspid regurgitation (TR). At issue is the medical necessity for an inpatient hospital stay.

The health plan's determination is upheld. 

This patient's inpatient hospitalization was not medically necessary.
The patient presented with vertigo and initial concern for stroke based on outpatient imaging. However, neuroimaging within 24 hours of admission (with MRI brain) ruled out an acute stroke, and other imaging (CTA head and neck) was negative for any significant intracranial stenosis that would have required inpatient monitoring or intervention. The patient's neurologic exam on admission was normal except for a mildly unsteady gait. She had no major electrolyte abnormalities and she was hemodynamically stable. She did not require continuous intravenous (IV) anticoagulation or blood pressure medication. She was not given tissue plasminogen activator (TPA).
The patient did not meet inpatient criteria using Milliman Care Guidelines, 22nd Edition, for the Neurology General Recovery Guidelines (GRG) subset.
Although she did have one of the listed new-onset severe neurologic findings (vertigo), this did not require inpatient care. Her management including imaging (CT, MRI), neurology consultation, orthostatic measurements, administration of medications, and a physical therapy evaluation could have been provided at a lower level of care.
The patient did not meet 2019 InterQual Level of Care criteria for inpatient admission using the General Medical: Stroke subset.