Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder - Intermittent Spasms.
Treatment: Hospital Admission.
The insurer denied Hospital Admission.
The denial is upheld. 

The patient is a male with an unremarkable past medical history who presented to the hospital with complaints of lower back pain with radiation to his legs. It was associated with numbness and tingling in his legs and also in his fingers. Over the course of several days, he had intermittent spasms in his extremities that briefly affected his function, including walking. The patient's brother noted spasms when the patient was asleep. The review of systems was positive for weight loss after changing his diet.
On the physical exam, the patient was afebrile. Blood pressure was 134/70, pulse rate was 110 beats per minute, respiratory rate was 20 breaths/minute, and oxygen saturation was 98% on room air. The patient was in no acute distress. He was a well-developed individual who was not ill appearing. His neurologic exam revealed memory and clear speech. His cranial nerves were unremarkable. The muscle strength was within normal limits, as well as reflexes. The Romberg test was positive. The evaluation of gait revealed difficulty with a tandem walk. The patient walked slowly.
Laboratory evaluation revealed that his white blood cell count was 8.4, hemoglobin was 14.8, hematocrit was 44.6, and platelets were 290. Sodium was 138, potassium was 4.6, chloride was 103, bicarbonate was 28, blood urea nitrogen (BUN) was 25, creatinine was 0.96, and glucose was 92. The urine drug screen was negative.
During the hospital stay, the patient was seen by a neurologist who stated that the patient received treatment with Ativan in the emergency department, which relieved his symptoms. According to the neurologist, the neurologic exam was unremarkable except for the brisk reflexes. The neurologist recommended obtaining an electroencephalogram (EEG) and checking the Ceruloplasmin level. The EEG was interpreted as organized in wake and sleep states. There were frontally predominant generalized sharp waves that were not clearly epileptiform. These waves were of uncertain significance. In addition, the patient underwent an electromyography (EMG) and nerve conduction studies that demonstrated no evidence of neuromuscular disorder. The lumbar magnetic resonance imaging (MRI) showed no acute pathology.
No definitive reason for the patient's symptoms was identified, therefore the patient was discharged from the hospital with a recommendation to take Baclofen 3 times a day and follow up with a movement disorder clinic.
At issue is the medical necessity of Hospital Admission.

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

No, the requested health service/treatment of Hospital Admission was not medically necessary for this patient.
Overall, this patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. The review of the medical records revealed that the patient's symptoms were not related to central nervous system (CNS) infection, prolonged altered mental status, or the presence of any significant structural brain abnormalities requiring intervention such as a cerebral aneurysm. There was no evidence that the patient had myasthenia gravis or multiple sclerosis requiring urgent intervention. The main neurologic symptom in this clinical case was spasticity or dystonia, which were not progressive or severe. It was clearly indicated that during the hospitalization these symptoms improved. Furthermore, while in the hospital, there was no evidence that these symptoms led to significant disability or severe pain. The severity of the patient's condition or the complexity of services provided did not rise to the acute inpatient level of care.
Therefore, the requested health service/treatment of Hospital Admission was not medically necessary.