Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right Side Neck Pain 
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

The patient is an adult male who presented to the emergency department with the complaint of right sided neck pain and heaviness on the right side including right side of face and right upper and lower extremity. The patient was on no medications and had no significant past medical history.

The patient was tearful and anxious with a subjective finding of decreased sensation to pinprick on that side. The patient's labs were essentially normal with normal electrocardiogram with incomplete right bundle branch block (IRBBB), normal chest x-ray, normal computed tomography (CT) of the head, normal and computed tomography of the ascending aorta and incidental narrowing of thoracic aorta. The patient was admitted for neurological observation. Medical therapy was limited to aspirin (ASA), statin, and deep vein thrombosis (DVT) prophylaxis. Further testing included magnetic resonance image (MRI) which showed disc bulging and a normal echocardiogram. Vascular consult was preformed and did not recommend any immediate intervention. The patient was discharged on aspirin, statin and outpatient follow up.

No, the proposed acute inpatient admission was not medically necessary as there was no indication for inpatient level of care.

Determination of level of care is primarily dependent on the actual care a patient receives and, whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results; and highlighted in the orders for care. 

In this case, the symptoms were atypical and unlikely to be representative of a neurological event that would require any intervention or complex testing. The patient's exam and all objective findings were normal.  The 4/5 decrease in pinprick sensation was subjective and not consistent with presentation. The finding of a narrowing of thoracic aorta was incidental, likely present for decades, and did not require any acute testing or intervention. Electrocardiogram (EKG) showed no evidence of acute ischemia. Chest x-ray was normal. Echocardiogram showed no wall motion abnormality.  The physicians' treatment did not reflect any serious concern about patient's acute condition. 

A letter of appeal was carefully considered but it offered no evidence to support inpatient level of care. The only care provided was telemetry and observation, frequently performed in a lower level of care. The patient was admitted for monitoring and subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care.  The statement that this patient could not be "managed" in an outpatient setting is not consistent with guidelines or usual community practice. This patient had no evidence of instability.  

While there is always a potential for an adverse event (and in this case a low probability), one did not happen and no actual treatment was added. There are no examples of care requiring inpatient level of care.

Milliman criteria requirements for admission were not fulfilled as there was never any evidence of acute coronary syndrome (ACS) present. Since all testing and therapy would be appropriate, safe and guideline consistent in a lower level of care, inpatient level of care was not medically necessary.

The denial explanation was consistent with guidelines and usual community care.