Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Rule out Stroke.
Treatment:  Inpatient Admission.

The insurer denied coverage for Inpatient Admission.  The denial is upheld. 

The patient is adult seeking coverage for inpatient admission. There was a history of type 2 diabetes mellitus (T2DM), and hypertension (HTN). The patient presented to the hospital due to left lid droop and visual problems. The patient was having pain with eye movements. The patient reported clear eye drainage and redness. The patient was having a worsening left eye lid droop which now closed their eye completely. The patient went to see an ophthalmologist who referred the patient to the Emergency Department (ED). There was a plan for magnetic resonance imaging (MRI) of the brain, orbits, and magnetic resonance angiogram (MRA). The patient was being admitted for left oculomotor nerve palsy. Vital signs of the patient noted blood pressure of 142/78, pulse of 61, respirations of 16, temperature 36.4 Celsius, and oxygen saturation of 99% on room air. MRI of the brain and MRA of the head and neck were negative.  Neurology felt that the patient may need computed tomography (CT) angiography to rule out aneurysm compressing the nerve. A CT angiogram of the head and neck was completed with no evidence of aneurysm. A transthoracic echocardiogram (TTE) showed a possible small patent foramen ovale. The patient was deemed appropriate for discharge with follow-up appointments.

An electrocardiogram noted sinus bradycardia at 57, left axis deviation, and nonspecific T wave abnormality. The patient had left ptosis and binocular diplopia x4 days. Ischemic stroke could not be ruled out. A transthoracic echocardiogram showed a possible small patent foramen ovale. 

The request was denied as the documentation did not identify chest pain, weight loss, abdominal pain, severe loss of fluid from the body, blockage of the bowel, blockage of the way urine flows, too much urine in the kidneys, numbness, weakness, confusion, or difficulty breathing. The patient's care could have been completed at observation level.

In this case, the patient presented to the hospital with left lid droop and visual problems. The patient underwent stroke work-up. It was argued that the inpatient admission was medically necessary for the patient. An electrocardiogram noted sinus bradycardia at 57, left axis deviation, and nonspecific T wave abnormality. The patient had left ptosis and binocular diplopia x4 days. An ischemic stroke could not be ruled out. A transthoracic echocardiogram showed a possible small patent foramen ovale. However, the documentation did not identify altered mental status, hemodynamic instability, cardiac arrhythmias of immediate concern, clinically significant cardiac or vascular disorder that required inpatient care, respiratory abnormalities, severe hypertension, suspected vasculitis, and need for urgent inpatient procedure, the documentation did not identify that cardiac telemetry monitoring was needed beyond 24 hours.  Thus, the patient's care could have been completed at a lower level such as observation level of care is upheld.

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.