Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stroke
Treatment: Inpatient hospital services
The insurer denied coverage for inpatient hospital services
The denial is upheld.

Acute stroke required exclusion. Acute stroke could be ruled-out in the emergency department with a head CT (computed tomography) scan and CT angiography, or if a smaller stroke is suspected, a rule-out brain MRI (magnetic resonance imaging). The patient can then be safely discharged once an acute stroke is ruled-out. The patient also had a modest increase in blood pressure, that could be safely treated with additional antihypertensives and did not require an acute level of care. There is no evidence of hemodynamic instability requiring hemodynamic monitoring. There is no evidence of any progressive neurological symptoms requiring intensive neurological monitoring. There is no suspicion of seizures, and the patient did not have uncontrolled hypertension. There was no need for cardiac monitoring. There was no need for pulmonary monitoring. There was no medication requiring frequent neurological checks or other monitoring. The patient did not receive Tissue plasminogen activator (tPA).

Therefore, the patient could have been safely evaluated in the emergency department (ED) or under observation. There is no indication for admission for an acute level of inpatient care.

Per Xiong, Y., Wakhloo, A. K., &amp; Fisher, M. (2022), the evolution of ischemic injury is quite variable among individual ischemic stroke patients and the pace of progression to irreversible ischemic injury, that is, infarction is dependent upon factors such as the adequacy of the collateral circulation, blood pressure, the metabolic milieu, temperature, and the age of the patient. With the help of advanced imaging techniques such as computed tomography (CT) perfusion and magnetic resonance imaging (MRI) diffusion/perfusion imaging this evolution can now be observed in individual patients.

Per Waqas, M., et al., (2019), in this review, we discuss the current evidence and practices surrounding safe and efficient triage in the emergency room. Clinical history is important in determining time of onset or last known well time, but alone or along with an examination, it cannot reliably predict a large vessel occlusion (LVO) or exclude intracranial hemorrhage and stroke mimics. The choice of imaging is influenced mainly by the duration of symptoms. On the basis of recent trials, patients presenting after the 6-hour therapeutic window can be considered for endovascular thrombectomy if the CT or magnetic resonance perfusion imaging shows favorable findings.

Initial patient triage in the ED can be broken down into several fundamental steps. It begins with early recognition of stroke patients and distinguishing these cases from non-stroke cases (stroke mimics may include seizure, syncope, and drug or alcohol intoxication). Once an acute stroke is suspected, the next steps are to distinguish Acute Ischemic Stroke (AIS) from a hemorrhagic stroke and to identify LVOs, tPA, and thrombectomy-eligible patients. The final steps involve the administration of tPA in intravenous tPA-eligible patients and notification of the neurointerventional team for consideration of endovascular thrombectomy (EVT) for LVO. Imaging is the only way to ascertain the presence of a LVO and exclude a hemorrhagic stroke. A noncontrast CT scan of the head is the most valuable initial investigation. It can be performed within seconds of evaluation requiring limited past history. This imaging modality has a high sensitivity and specificity for diagnosing hemorrhagic stroke. Magnetic resonance imaging (MRI) is highly sensitive for the detection of early ischemia. However, it is less readily available, needs clearance to exclude certain implants, and takes longer to perform.

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 inpatient hospital services is not substantiated.