Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Inpatient Hospital. 

The insurer denied Inpatient Admission. 
The denial is upheld. 

The patient at time of presentation, was a female with a past medical history significant for hypertension, migraine headaches, and rheumatoid arthritis who was brought to the emergency department because of complaints of right temporal headache which she rated as 8/10 in intensity. This was associated with slurred speech and facial drooping. The patient also complained of nausea and 3 episodes of vomiting. The patient denied fever, chills, cough, abdominal pain, shortness of breath, chest pain, leg pain, and swelling. On the physical exam, the patient was afebrile. The blood pressure was 150/77, pulse rate was 105 beats per minute (bpm), respiratory rate was 18 breaths per minute, and oxygen saturation was 97% on room air. 
The patient was alert, cooperative, and in no acute distress. The head, eyes, ears, neck, throat (HEENT) exam was within normal limits. The patient was alert and oriented times 3. Cranial nerves were normal. There was a normal motor and sensory function, with no facial droop noted. The cerebellar function was intact. The tissue plasminogen activator (TPA) was not administered since the stroke symptoms started more than 3 hours before the presentation. Imaging studies included a computed tomography (CT) scan of the head, which demonstrated no evidence of acute intracranial abnormality. 
The patient was admitted to the hospital with a diagnosis of cerebrovascular accident (CVA) versus transient ischemic attack (TIA). Another consideration was given to migraine headaches, for which the patient received intravenous Ketorolac. The computed tomography (CT) angiogram of the head revealed occlusion of the Sylvian (M2) branches of the right middle cerebral artery (MCA) consistent with restricted diffusion on the magnetic resonance imaging (MRI) scan of the brain from the same date. The MRI of the brain demonstrated acute or subacute infarctions in the right parietal and temporal regions as well as a right parietal and temporal operculum.
In the hospital, the patient was seen by a neurologist. The neurologist stated that the patient had acute versus subacute infarctions in the right parietal and temporal regions as well as a right parietal and temporal operculum. The neurologist recommended treatment with aspirin, Plavix, and Lipitor. She received treatment with potassium supplements because of hypokalemia. 
At issue is the medical necessity of Inpatient Admission. 

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

The requested health service/treatment of Inpatient Admission was not medically necessary for this patient. 

Based on the nationally accepted standards of care, the admission at the acute inpatient level of care is generally indicated for patients with acute ischemic stroke with neurologic findings whose National Institute of Health Stroke Scale (NIHSS) score is greater than two, and when there is evidence of hemorrhagic transformation, altered mental status, significant dysphasia, aphasia, and gait impairment. This was not present in this clinical case. The brain imaging studies did not demonstrate evidence of edema or large acute infarction. According to the consultation note from the neurologist, the patient's NIHSS score was 1. There was no evidence that the patient had respiratory abnormalities associated with acute stroke. There were no reports of severe uncontrolled hypertension requiring any intervention. There was no need for any urgent procedures such as thrombectomy or thrombolysis. There was no need for parenteral anticoagulation. 
The patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.
Therefore, the requested health service/treatment of Inpatient Admission was not medically necessary for this patient.