Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right side facial numbness
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld.

This case involves an adult who presented to the emergency department (ED) claiming to have awakened with right-sided face numbness/weakness. He was subsequently admitted for further work-up and care. The initial assessment noted the patient had right lower extremity drift and stroke protocol was initiated. Vital signs were relatively stable with a temperature of 98.8 degrees F (Fahrenheit), heart rate 97, blood pressure 130/89, respirations 18, and pulse oximetry at 99%. He reported right-sided neck pain the night before symptoms began and claimed to have left eye blurriness the night before at around 11:00 PM. He denied dizziness, headaches, palpitations, chest pain, shortness of breath, and claimed to have finished Tamiflu the day prior following a diagnosis of the flu 3 days before. The patient was alert and oriented and had a Glasgow Coma Scale score of 15. He had full range of motion of all extremities and was able to void urine without difficulty. Hand grasp and leg strength were strong with equal findings bilaterally. The report stated the patient had a history of Barrett's esophagus, complaints of right facial droop, right arm weakness, right leg weakness. Computed tomography (CT) and CT angiogram were without significant findings. The patient was on empiric aspirin and atorvastatin with plans to continue monitoring with serial neurological examinations. 

He realized that morning that while brushing his teeth, water dripped from his mouth, and he was unable to close his right eye. When he presented to the emergency department, his symptoms of right upper extremity numbness and tingling had since resolved. He was still unable to close his right eye, although his tongue was midline with no other neurological abnormalities noted. The patient was documented with a National Institutes of Health (NIH) stroke scale score of 1. The patient obtained a magnetic resonance imaging (MRI) of the brain, which revealed no significant findings. It was determined that symptoms were likely related to Bell's palsy. The patient was subsequently discharged the same date after a period of hemodynamic stability. 

According to the Milliman Care Guidelines (MCG), inpatient admission may be indicated when the patient has signs of acute ischemic stroke with neurologic findings that warrant inpatient care to include 1 or more of the following such as an National Institutes of Health stroke scale score greater than 2, evidence of hemorrhagic transformation, altered mental status, dysphagia that warranted evaluation, significant arm or leg weakness, aphasia, gait impairment, finding on brain imaging that requires inpatient care to include mass, edema, or large acute infarction, or when clinical stability is unclear. Inpatient admission may be indicated for hemodynamic instability, cardiac arrhythmias of immediate concern, when there is clinically significant cardiac or vascular disorder identified, respiratory abnormalities, severe hypertension to include systolic blood pressure greater than 180 or distally blood pressure greater than 120, or greater than 95th percentile for age, gender, and height +30 in pediatric patients, prolonged cardiac telemetry monitoring needs beyond 24 hours, suspected vasculitis, or if the individual is pregnant. 

The documentation provided for the review did not support that the patient met any of the above criteria to justify inpatient admission. He could have had his care safely and effectively rendered on an outpatient basis or observational basis.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is not substantiated.