Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems-Stroke/CVA/TIA
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

The patient has no significant past medical history and presented to the emergency department with complaints of tongue numbness for one week. He complained of his tongue feeling heavy and numb. These symptoms were aggravated by talking and resolved when he stopped. The patient denied any headache, weakness, difficulty swallowing, nausea, and vomiting. His review of systems was negative for fever, chills, weight loss, cough, shortness of breath, and wheezing. It was also negative for chest pain, leg swelling, and gastrointestinal symptoms. On the neurologic exam, there were no focal deficits present. The patient was awake, alert, and oriented to person, place, and time. The cranial nerves were within normal limits. There were no sensory deficits. There was no weakness. The psychiatric exam revealed a normal mood. The patient underwent a computed tomography (CT) scan of the head without contrast and a CT angiogram of the head with contrast. The studies did not show acute abnormalities. The patient was seen by a neurologist.  The patient underwent a magnetic resonance imaging (MRI) scan and magnetic resonance angiography (MRA) scan of the brain and neck. The studies were negative for acute stroke or any clinically significant abnormalities. The echocardiogram was performed and was clinically unremarkable. The neurologist recommended outpatient follow-up in the neurology clinic. During the hospital stay, the patient remained in stable clinical condition and was discharged. 

The hospital stay was not medically necessary for this patient at the acute inpatient level of care. Based on the initial evaluation of the patient, it was possible that the patient could have transient ischemic attack (TIA).
According to the nationally accepted standards of care, the acute inpatient level of care is generally indicated in cases of the transient ischemic attack associated with hemodynamic instability, persistent or recurrent focal neurologic signs. In this clinical case, it was not clear if the patient's symptoms represented neurologic signs. The admission at the acute inpatient level of care is also required for patients with TIA associated with altered mental status, cardiac arrhythmias of immediate concern, a clinically significant cardiac disorder such as severe valvular disease, atrial myxoma, cardiomyopathy, cases of severe hypertension that could not be controlled by the emergency department or at a lower level of care, certain cases when patients require an inpatient procedure or surgery such as endarterectomy, also in cases when parenteral anticoagulation or administration of antiplatelet agents is required. The review of the medical records clearly demonstrated that in this clinical case the patient had no circumstances listed above.
An admission in the hospital for observation of the patient was indicated to rule out acute stroke and perform all necessary workup that was indicated, considering the clinical circumstances. However, the workup and clinical monitoring could have been performed at a lower level of care.  Overall, he remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. The hospital stay was short and was within the scope of a lower level of care.