Appeal type: Medical necessity
Decision: Upheld

The patient is a female with a reported history of diabetes mellitus type 2, venous thromboembolism including physical exam (PE) and deep vein thrombosis (DVT), and supposedly multiple sclerosis who was brought in by medics to the Emergency Department for an emergency evaluation due to new-onset, severe bilateral leg weakness, tingling, and numbness, which was complicated by an accidental fall on the stairs at the train station, in which the patient fell onto her back. At the time of admission, she reported acute bilateral lower extremity and back pain and persistent weakness, limiting her ability to walk. She also reported recent cough and cold symptoms. She took Prednisolone daily for multiple sclerosis, morphine for chronic back pain, and reported recent non-adherence to outpatient anticoagulation for chronic venous thromboembolism.

At the time of admission, the patient was evaluated by admitting attending who stated in the history and physical exam note that she generally agreed with the resident's history and physical (H&P) note with some exceptions. According to the attending, the patient was not compliant with her home regimen of medications and had also demonstrated drug-seeking behavior on multiple occasions in the past.
It was indicated that the patient was admitted under similar circumstances to a different hospital just 1 month before the day of the current admission and refused to get a magnetic resonance imaging (MRI). At that time, she signed out from the hospital against medical advice.

The admitting attending indicated that there was no evidence that the patient, in fact, had multiple sclerosis, except for the patient continued to claim it.

Therefore, the admitting attending decided not to give the patient any pain medications and no need to re-consult neurology. After the patient learned that she was not going to get any pain medications, she left the hospital against medical advice.

The health plan's determination is upheld. 

This patient presented to the hospital after reportedly falling on the stairs at the train station. She complained of weakness associated with tingling and numbness of the right side of her body in the past 2 days.
On initial exam the patient reportedly had a focal weakness with diminished strength rated as 4/5 on the right upper extremity and right lower extremity. While in the hospital, the patient continued to complain of pain and stated that Morphine and Oxycodone make her nauseated. She requested Dilaudid.
She refused an MRI during this admission, as well as during the previous admissions. The patient stated that she was allergic to multiple medications that are usually used in cases of multiple sclerosis such as Gabapentin, Lyrica, Baclofen, Robaxin. The patient was explained that narcotics would worsen her nausea and vomiting, and that these medications should be avoided.

At that point in time, the patient became angry and verbally abusive, and decided to leave the hospital. At that time, the patient "was seen afterward walking without cane jumping on floor with no sign of weakness."

Taking into consideration all these facts, it is unclear based on the records provided whether the patient had an acute exacerbation of multiple sclerosis. Therefore, there were no clinical indications that this patient required admission at the acute inpatient level of care.