Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Upper extremity weakness,
Treatment: Inpatient Hospital Stay,
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a patient with a past medical history of chronic back pain, anxiety, and a celiac artery aneurysm resulting in a stroke for which he received tissue plasminogen activator (TPA) five days before the presentation. He came to the emergency department with complaints of right eye blurriness and right upper extremity weakness, essentially the same symptoms that brought the patient to the hospital five days before the current presentation. Reportedly, the patient was discharged from the hospital several days before the current presentation with the recommendation to take blood thinners, but the patient was not compliant with the treatment.
On the physical exam, the patient was afebrile. His heart rate was 106 beats per minute (bpm), respiratory rate 18 breaths/minute, and oxygen saturation 97%(percent) on room air. The skin was warm and dry. The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. The neck was supple without lymphadenopathy, masses, jugular vein distention (JVD), and carotid bruits. The lungs were clear to auscultation without wheezes, rales, or rhonchi. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. The abdomen was soft, non-tender to palpation, with normal bowel sounds, without guarding or rebound. On the neurologic exam, the patient was alert and oriented times four. There was normal muscle strength and sensation in the left upper extremity, and slightly diminished muscle strength in the right upper extremity and left lower extremities. The rest of the physical exam was unremarkable.

A computed tomography (CT) scan of the head showed no evidence of acute intracranial hemorrhage or a large territory infarct. Imaging studies, including a CT angiogram of the head and neck, were interpreted as negative studies.
The patient was admitted to the hospital with right eye blurriness and right upper extremity weakness. Magnetic resonance imaging (MRI) of the brain, a transthoracic echocardiogram, and neurologic consultation was ordered. During the hospital stay, the patient was seen by a neurologist who recommended an MRI of the brain, however, the patient elected to leave the hospital against medical advice on the date of admission.
At issue is the medical necessity of an inpatient stay.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
The patient presented to the hospital with neurologic symptoms that were essentially the same as those reported during his previous admissions just 5 days before the presentation.
His neurologic exam was only slightly abnormal and it was not clear if the abnormalities, including slightly decreased muscle strength, represented residual findings related to a recent stroke, or were new findings.
Regardless, there were no reports that the patient had altered mental status, cardiac arrhythmias of immediate concern, clinically significant cardiac disorder, or severe hypertension that could not be controlled by the emergency department or at a lower level of care.
Considering the presence of abnormal neurologic symptoms as well as abnormalities seen on the physical exam, admission for observation was completely reasonable to determine if the patient had an acute stroke or if these symptoms represented residual findings related to the previous stroke. There is not overwhelming evidence that either the severity of the patient's condition or the complexity of services provided rose to the acute inpatient level of care.
There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care, rather than admission to an inpatient level of care.  Overall, this patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.