Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems-Stroke/CVA
Treatment: Inpatient Hospital Stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld the health plan denial.

This is the case of a patient with a past medical history of diabetes mellitus, hypertension, anemia, thyroid disease, obesity, and supraventricular tachycardia, who presented to the emergency department with left-sided weakness that began two hours prior to presentation in addition to dizziness and decreased sensation to the left side of  tongue, in addition to mid-sternal squeezing chest pain the night before.

On presentation, the patient was afebrile with stable vital signs. Exam otherwise noted left upper extremity strength to be 4/5 with no other focal neurologic deficits or other acute exam abnormalities noted. Labs resulted with a white blood cell count 6.2, Hemoglobin 12, Platelets 299, sodium 130, potassium 4.8, blood urea nitrogen 12, creatinine 0.45, glucose 354, troponin unremarkable, and blood gas unremarkable. A computed tomography (CT) scan of the head, CT angiogram of the head and neck, and CT angiogram of the chest, abdomen, and pelvis noted no acute process. Electrocardiogram (EKG) showed normal sinus rhythm without acute ischemia. The patient was brought into the hospital with concerns for possible acute ischemic stroke with plans for telemetry, magnetic resonance imaging (MRI) scan of the brain, duplex of the carotids, aspirin, Lipitor, trending troponins, and serial neurologic exams.

The patient was subsequently seen by neurology with assessment that patient had symptoms of anxiety with no focal deficits noted on exam, and with no need for further work-up for stroke. The patient was noted to have no new neurologic deficits and was subsequently discharged home.

The inpatient hospital admission was not medically necessary. This is a patient who presented with concerns for chest pressure the night prior in addition to left sided weakness. The patient was hemodynamically stable on presentation, with all negative imaging in the emergency department, and with troponin and EKG unremarkable for cardiac ischemia. Given the risk factors for stroke including hypertension, obesity, and diabetes, and history of supraventricular tachycardia, it was certainly reasonable to bring the patient into the hospital for further monitoring on telemetry and consideration of stroke work-up, and neurology consultation. It is noted, however, that once she was seen by neurology, the possibility of stroke was felt to be extremely unlikely, with assessment the patient likely had symptoms related to anxiety, with no other new medical issues noted, and with the patient discharged after one midnight of care. It is unclear why this patient presenting with a question of mild upper extremity weakness and chest pain without troponin or EKG suggestive of ischemia or arrhythmia and all negative imaging in the emergency department could not have been safely cared for at a lower level of care with telemetry, serial neurologic checks, and neurology consult. Inpatient level of care was not medically necessary, and a lower level of care services were appropriate.