Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder - Sudden onset of numbness. 
Treatment: Inpatient Hospital. 

The insurer denied a full hospital admission. 
The denial is upheld. 

The patient is a male with a past medical history significant for hypertension and diet-controlled diabetes who presented to the hospital with sudden onset of numbness on the right side of his lip. The patient tried to brush his teeth and noticed that the water fell out of his mouth. Reportedly, his wife noticed some changes in his voice. Therefore, Emergency Medical Services (EMS) was dispatched. When the patient was seen by the admitting physician he continued to complain of some right-sided upper nasolabial area numbness and tingling. The patient was unable to puff out his cheeks. In addition, the patient complained of left-sided back pain that was aggravated by movement. The back pain started after the patient lifted a heavy weight 10 days before the presentation.  Blood pressure was 156/109, respiratory rate was 18 breaths per minute, heart rate was 84 beats per minute (bpm), and oxygen saturation was normal. The physical exam was unremarkable. On the neurologic exam, the patient had normal muscle strength in all 4 extremities. Right nasolabial and perioral numbness was documented. The patient had clear speech. 

Laboratory evaluation revealed that sodium was 140, potassium was 3.7, chloride was 105, bicarbonate was 25, blood urea nitrogen (BUN) was 11, creatinine was 1.2, and glucose was 120. Sodium was 7.8, hemoglobin was 14.1, hematocrit was 41.1, and platelets were 215. Urinalysis was unremarkable. 
A computed tomography (CT) scan of the head demonstrated no acute intracranial hemorrhage. CT angiogram of the neck revealed no high-grade stenosis in the carotid arteries. CT angiogram of the head showed no high-grade large vessel intracranial artery occlusion. A chest x-ray showed no evidence of acute cardiopulmonary process. 
The patient was admitted to the hospital to rule out cerebrovascular accident (CVA). During the hospital stay, the patient underwent a magnetic resonance imaging (MRI) of the brain that demonstrated no acute intracranial pathology. Nonspecific white matter changes, which likely represented chronic microvascular ischemic changes, were seen. 
In the hospital, the patient was seen by a neurologist who recommended treatment with Aspirin and Lipitor as well as permissive hypertension. On the next day after the day of admission, the patient decided to sign out against medical advice (AMA). 
At issue is the medical necessity of a full hospital admission. 

The health plan's determination of medical necessity is upheld in whole. 

No, the requested health service/treatment of a full hospital admission was not medically necessary for this patient. 

Based on the initial evaluation, the patient was suspected to have a CVA versus (vs) transient ischemic attack (TIA). According to the nationally accepted standards of care, the acute inpatient level of care is generally indicated in cases of transient ischemic attack associated with hemodynamic instability, and persistent or recurrent focal neurologic signs. 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, certain cases when patients require inpatient procedure or surgery such as endarterectomy, and 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 none of these circumstances. 
Therefore, the requested health service/treatment of a full hospital admission was not medically necessary.