Appeal type: Medical necessity
Decision: Upheld

The patient is a male with a past medical history significant for diabetes mellitus, hypertension, legal blindness, and chronic kidney disease stage III who presented to the emergency department with sudden onset of right-sided numbness. The numbness started the night that preceded the day of admission. It went away, and then the patient woke up in the morning with a right-sided numbness and weakness in the right leg.

On the neuro exam, the patient was awake, alert, and oriented times three, he had good concentration. His muscle strength was 4/5 in the right lower extremity. The rest of the exam was unremarkable.
Laboratory evaluation revealed that sodium was 140, potassium 4.1, chloride 102, bicarbonate 28, blood urea nitrogen (BUN) 21, creatinine 1.93, and glucose 154. Liver function tests were within normal limits. Troponin was normal. Creatine phosphokinase (CPK) was slightly elevated at 557. White blood cell count was 5.36, hemoglobin 13.3, hematocrit 39.7, platelets 274.
Electrocardiogram (EKG) demonstrated normal sinus rhythm and left ventricular hypertrophy (LVH). Computed tomography (CT) scan of the head demonstrated scattered chronic ischemic changes in both hemispheres with volume loss. No acute intracranial abnormalities were reported on the CT scan.
The patient was admitted to the hospital to rule out an acute stroke. In the hospital, he was seen by a neurologist who indicated that the patient had subjective paresthesia and mild motor weakness in the right leg. The rest of the neuro exam was unremarkable. The neurologist suggested that the patient could have transient ischemic attack (TIA) and recommended magnetic resonance imaging (MRI) of the brain, carotid Dopplers, echocardiogram, and electroencephalogram (EEG).
MRI of the brain was performed and demonstrated chronic ischemic changes in the white matter of both hemispheres as well as midbrain and ponds. There was no evidence of acute ischemia.
Echocardiogram was performed and revealed normal left ventricular ejection fraction, no significant valvular abnormalities. The EEG demonstrated a mild to moderate degree of diffuse cerebral slowing.
Since the patient remained in stable clinical condition, he was discharged home the next day after the day of admission.

The health plan's determination is upheld.

The review of the medical records demonstrated that the patient presented to the hospital with relatively mild symptoms that were stable throughout the entire short period of hospitalization.
The patient had complaints of intermittent right-sided numbness and was found to have slightly diminished motor strength in the right lower extremity.
At the time of the initial evaluation and during the very short period of hospitalization, this patient was afebrile and hemodynamically stable.
There was no evidence that the patient had significant neurologic deficits except for the mildly decreased strengths in the right lower extremity. The patient's sensation was normal despite complaints of subjective paresthesias. He had normal reflexes and normal cranial nerves on the exam. There was no evidence of any speech or gait disturbances. The results of the laboratory studies and diagnostic tests were not alarming.
During the hospital stay the patient underwent a thorough evaluation, including MRI of the brain, that did not demonstrate evidence of acute stroke.
During the hospital stay, there was no evidence that the patient had any seizures or arrhythmias of immediate concern. There was no mention of worsening neurologic symptoms during hospitalization.
There was no need for any procedures or parenteral administration of anticoagulants or antiplatelet medications.
Overall, the patient's clinical condition was stable, and he was discharged home the next day after the day of admission.
Taking into consideration all these facts, the admission for monitoring was definitely indicated, based on significant risk factors for acute stroke that the patient had. At the same time, his neurologic symptoms were limited to slightly diminished motor strength in the right lower extremity, which did not correlate with the negative results of the MRI of the brain.
There were no procedures performed during the hospital stay that would necessitate admission at the acute inpatient level of care.
The workup that was performed in the hospital did not require admission at the acute inpatient level of care.