Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebrovascular accident
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned in part.

The patient with a past medical history significant for hypertension and tobacco use disorder was brought to the emergency department after she developed dizziness and double vision. When her symptoms started, she was lying in bed, not doing any activity at that time. The double vision improved after covering one eye.
There were no complaints of a headache or unilateral weakness in the extremities. The patient denied a fever, cough, rigidity. She denied any gait changes.
In the emergency department, the patient was found to have very high blood pressure. She underwent a computed tomography (CT) scan of the head that demonstrated small vessel disease. A computed tomography (CT) angiogram of the head revealed no significant stenosis or aneurysm. In the ER, she received treatment with Labetalol and her blood pressure came down from 223/124 to 155/86.
When seen by the admitting physician, the patient was afebrile. The pulse rate was 86 beats per minute (bpm), respiratory rate 19 breaths/minute, blood pressure 146/95, and oxygen saturation 90% on room air.
The patient appeared in no apparent distress. She had a left-sided gaze preference of the left eye and was unable to move her left eye medially.
The neck was supple without lymphadenopathy, masses, jugular vein distention (JVD), or carotid bruits. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. There were decreased breath sounds on the pulmonary exam. The abdomen was soft, non-tender to palpation, with normal bowel sounds, without guarding or rebound. The patient had a depressed affect but the rest of the neurologic exam was unremarkable.
Laboratory evaluation revealed that the white blood cell count was 8.9, hemoglobin 16.4, hematocrit 48.8, and platelets 167.
The sodium was 142, potassium 3.5, chloride 110, bicarbonate 24, blood urea nitrogen (BUN) 20, creatinine 0.6, and glucose 99. Serial troponins were normal.
Based on the patient's symptoms, an acute cerebrovascular accident (CVA) was suspected since the patient presented with diplopia. The patient was started on Aspirin and Lipitor.
A magnetic resonance imaging (MRI) scan of the brain was ordered. It demonstrated restricted effusion in the posterior aspect of the brainstem at the junction of the midbrain and the pons. This was consistent with acute infarct.
During the hospital stay, the patient underwent a lumbar puncture that was performed to rule out atypical Guillain-Barre syndrome.
The patient underwent a transesophageal echocardiogram (TEE). The study demonstrated mild left atrial dilatation and moderate aortic stenosis as well as a trace of pulmonary regurgitation. The rest of the study was normal.
During the hospital stay, the patient's clinical condition somewhat improved. Her blood pressure was much better controlled. The workup of an acute stroke was completed, and the patient was transitioned to outpatient care.
At issue is the medical necessity of an inpatient stay.

The inpatient stay was medically necessary in part.  The admission at the acute inpatient level of care was justified for the first 4 days when the patient was actively evaluated for acute stroke and possibly other reasons that contributed to her symptoms. 
Admission at the acute inpatient level of care was justified initially when the patient presented to the hospital with the new onset of neurologic symptoms including diplopia and extremely high blood pressure. It is a common clinical practice to admit the patient at the acute inpatient level of care in cases of hypertension associated with cerebral infarction, which was confirmed in this case. This patient required very close monitoring of neurologic signs as well as close monitoring of blood pressure at least in the first 48 hours after the onset of symptoms when permissive hypertension is allowed.
However, subsequently, the patient's neurologic symptoms improved. She underwent an MRI of the brain which demonstrated evidence of a stroke.
By that time, the patient already had a transthoracic echocardiogram performed.
The patient also underwent a lumbar puncture, which was performed to rule out atypical Guillain-Barre syndrome.
It was determined that the patient's symptoms were related to an acute infarct without any other additional neurologic conditions. At that time, the final recommendations from the neurologist were made, including a continuation of treatment with aspirin and a statin.
By that day, the patient remained in stable clinical condition with her blood pressure being reasonably well controlled.
The admission was justified based on the accepted standards of care. However, there was not an overwhelming benefit for the patient to stay in the hospital beyond the first 4 days.