Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis:  Stroke.
Treatment:  Continued admission.

The insurer denied coverage for continued admission.  The denial is modified.

This case involves an adult patient with a history and physical reporting the patient had a history of multiple Cerebrovascular Accidents (CVAs). The patient reported an onset of blurry vision and elevated blood pressure. The patient was hospitalized at another facility for 1 week and discharged home. After being discharged the patient developed left facial weakness and was again admitted. Imaging demonstrated right middle cerebral artery (MCA) stenosis, and the patient was recommended for transfer for possible bypass surgery. An operative report reported the patient underwent a cerebral angiogram. A progress note reported the patient had worsening edema. The patient continued to have extreme weakness in the upper and lower extremities. A rheumatology note reported biopsy results were still pending. The recommendation was to continue Cytoxan. A social work note reported therapy discharge recommendations were for acute rehabilitation. The patient and family were aware and in agreement. It was noted per stroke services the patient was nearing readiness for discharge. A neurology note reported a repeat computed tomography angiogram (CTA) was completed, and there was no significant change. It was noted that the patient may require Digital Subtraction Angiography (DSA) to ensure no further vasculitis changes. The stroke progress note reported the patient had complaints of headache. The rheumatology note reported interdisciplinary discussion resulted in switching the patient to azathioprine given toxicity associated with Cytoxan. The neurology attending note reported there was discharge planning. The appeal letter reported the patient was initially admitted as a transfer for a new right MCA stenosis with left upper extremity weakness. The patient was taken to the operating room for a right decompressive hemicraniectomy and a right frontal lobe brain biopsy. The provider indicated the patient was awaiting biopsy results and insurance authorization for transfer to an acute rehabilitation facility. The determination letter reported the prior denial was upheld. It was stated that the medical records did not show that the patient had a severe medical problem to warrant ongoing inpatient level of care.

The continued admission in full is not considered medically necessary for this patient. The patient underwent decompressive hemicraniectomy and brain biopsy. Continued stay beyond this was supported in part for ongoing treatment planning to include biopsy results and medication adjustments. It appears delay in the discharge was for insurance approval and availability of acute rehab facility. The ongoing stay in full was not medically necessary, as the patient was medically stable for discharge to a lower level of care. As such, the continued admission in full is not considered medically necessary for this patient.

Based on the above, the insurer's denial must be modified to allow partial continued admission. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for partial continued admission is substantiated. The medical necessity for continued admission in full is not substantiated.