Appeal type: Medical necessity
Decision: Upheld

 
Diagnosis: Left Sided Weakness

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

The patient presented to the emergency department (ED) for the complaint of left sided numbness. The patient reported that it felt like pins/needles/ants crawling on their arms.  The next day, the patient's fraction of inspired oxygen (FiO2) was increased to 60% because the patient was desaturating.

The patient has a past medical history (PMHx) of hypertension (HTN), diabetes mellitus (DM), and chronic obstructive pulmonary disease (COPD) on home oxygen with left sided numbness. The patient woke up with left arm numbness and tingling. The patient also endorsed mild soreness in the left shoulder. The patient denied chest pain, fever, chills, abdominal pain, or nausea, vomiting, diarrhea, or constipation. The patient was alert and oriented x3, cranial nerves III-XII were tested and were intact, and sensation was grossly intact in all extremities. Strength tests and bilateral wrist flexion/extension were within normal limits. 

In the ED, the patient's venous blood gas (VBG) had a pH of 7.31 and partial pressure of carbon dioxide (pCO2) was 70.2. The patient's computed tomography (CT) head showed no acute intracranial abnormality.  CT angiogram head and neck showed no vascular occlusion. Lungs revealed diminished breath sounds.  Chest x-ray (CXR) showed cardiomegaly with chronic interstitial lung disease. Troponins were 53.6 and  51.8, not reflective of an acute event. The patient removed nasal cannula and was noted to be hypoxic at 77%. The patient's oxygen (O2) increased to 10 liters per minute (lpm) and their oxygen saturations improved to 83%, so the patient was placed on a non-rebreather and their O2 improved to 92%. The patient was evaluated by neurology and a magnetic resonance imaging (MRI) was ordered to rule out cerebrovascular accident (CVA). The patient was admitted for further management. 

The patient's MRI showed scattered white matter lesions that are nonspecific but consistent with microvascular ischemic white matter change, no intracranial hemorrhage, mass effect or acute infarct. The patient was waiting for transthoracic echocardiogram (TTE) but the patient stated that they would like to follow up with their cardiologist. The patient was seen by rehab who recommended home when stable. 

The medical records submitted for review did not indicate any evidence of ischemic stroke, CT head showed no acute intracranial abnormality, CT stroke angiogram head and neck showed no vascular occlusion, and chest x-ray showed cardiomegaly with pulmonary edema. Although, the patient desaturated, as noted it is due the patient being not compliant and removing their nasal cannula. 

According to the referenced literature, transient ischemic attack and minor stroke patients presenting to the ED with a National Institutes of Health Stroke Scale score of 5 or less and nondisabling deficit were assessed for potential discharge to Rapid Access Vascular Evaluation Neurology (RAVEN) with a protocol incorporating social and medical criteria. Outpatient evaluation by a vascular neurologist, including vessel imaging, was performed within 24 hours at the RAVEN clinic. Participants were evaluated for compliance with clinic attendance and 90-day recurrent transient ischemic attack and minor stroke and hospitalization rates.

Due to the negative results of the imaging, the care given is most appropriate in a lower level of care such as outpatient evaluation and treatment in emergency department, rapid treatment site, urgent care center, or medical office. 

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 hospital admission is not substantiated.