Appeal type: Medical necessity
Decision: Upheld

This is a patient with a past medical history significant for coronary artery disease, hypertension, hyperlipidemia, cerebrovascular accident (CVA), diabetes mellitus, osteoarthritis, and ataxia who presented to the emergency department with complaints of intermittent dizziness for two months. His symptoms were mild and intermittent. They were alleviated by laying down and aggravated by ambulation. The patient said that he had a sensation that "the room was spinning around."
There were no other accompanying symptoms such as chest discomfort, palpitations, shortness of breath, headache, nausea, vomiting, visual or auditory disturbances, fever, chills. The patient denied any previous head injury or fall. The review of systems obtained at the time of admission was otherwise negative.
On exam, the patient was awake, alert and oriented times () 3. His head, eyes, ears, neck, throat (HEENT) exam was within normal limits. Lungs were clear to auscultation. The patient had a regular rhythm with a murmur. The abdominal exam was unremarkable. On the neurological exam, the patient had a mild left-sided weakness. There were no sensory deficits. The patient had moderate ataxia. The rest of the physical exam was unremarkable.
Laboratory evaluation revealed that his white blood cell count was 5.8, hemoglobin 10.9, hematocrit 34.0, and platelets 252. Troponin was 0.48. Sodium was 138, potassium 3.8, chloride 102, bicarbonate 29, blood urea nitrogen (BUN) 13, creatinine 0.9, and glucose 178. A urinalysis was unremarkable.
A computed tomography (CT) scan of the head demonstrated no intracranial hemorrhage or acute infarction. The patient had a 1.3 x 1.1 centimeter (cm) midbrain/pontine hypodensity.
At the time of admission, the patient was diagnosed with CVA, elevated troponin, coronary artery disease, diabetes mellitus, hemiplegia.
In the hospital, the patient was seen by a cardiologist who noticed slightly elevated troponin levels. The cardiologist was not sure if it was related to acute coronary syndrome since the patient had no symptoms including chest pain or palpitations. An echocardiogram was performed and demonstrated a normal ejection fraction.
During the hospital stay, the patient underwent a CT angiogram of the head and neck. It revealed no intracranial or extracranial arterial stenosis, filling defect, or aneurysm formation.
During the hospital stay, the patient was seen by a neurologist, who indicated that the patient had a previous history of a stroke. There was no evidence of an acute stroke at this time. The neurologist suggested performing several diagnostic studies and laboratory tests that could help find out why the patient had a stroke when he was in his 40s. Reportedly, treatment with Plavix was initiated. In the hospital, the patient was seen by an endocrinologist.
It was noted that the patient's vitamin B12 level was low, and the patient was started on vitamin B12 supplements.
In the hospital, the patient remained in stable clinical condition and was discharged home. At issue is the medical necessity of an inpatient stay.
The health plan's determination is upheld. A review of the medical records did not demonstrate that either the severity of the patient's condition or the complexity of the services provided justified acute inpatient admission on the dates of service. The patientt presented with intermittent dizziness, there was no evidence that he had a serious medical problem that would contribute to his symptoms and required admission at the acute inpatient level of care. The patient had no new neurological deficits. His mild left-sided weakness was most likely attributed to the previous strokes. Diagnostic studies ruled out a cerebral hemorrhage. There were no alarming features on the neurological exam except for the left-sided muscle weakness most likely related to the previous stroke.
Even though his troponin level was slightly elevated, there were no clinical signs of the acute coronary syndrome. There was no evidence that the patient's symptoms were related to acute infection.
There was no evidence that the patient had other medical conditions that would necessitate admission at the acute inpatient level of care.
Taking into consideration all of this information, the care could have been provided at a lower level to rule out acute coronary syndrome or acute stroke. At the same time, the review of the medical records did not reveal overwhelming evidence that the patient had any significant medical problems that would justify admission at the acute inpatient level of care.