Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left Eye Excessive Blinking, Pain In The Ear, Loss Of Sensation Of Taste And Weakness Of The Left Side Of Face. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 

The denial is upheld. 

The patient is a male teen with medical history significant for pre-diabetes. He presented to the ED (emergency department) with three-day history of constant left ptosis, inability to close his right eye, left-sided tongue numbness, and right posterior neck pain. The neck pain was described as sharp and shooting and preceded the other symptoms by several days. He had no history of trauma or infectious symptoms. 

The patient's vital signs included temperature 37, heart rate 99, respiratory rate 20, and blood pressure 134/82. His examination was significant for non-toxic appearance, no acute distress, ptosis of the left eye, no drooling or slurred speech, right upper lid unable to hold eyelid closed, slowness of right eye medial gaze, no visual field deficits, no diplopia, normal range of motion of his neck, no gross cranial nerve deficits including facial asymmetry, and overall non-focal neurologic exam. Laboratory evaluation was significant for mild thrombocytosis (415K [thousand]), mildly elevated transaminases (ALT [alanine aminotransferase] 81, AST [aspartate aminotransferase] 52), and Covid negative. CT (computed tomography) scan without contrast was unremarkable. 

The patient was admitted for further monitoring, Neurology evaluation, and MRI (magnetic resonance image). Admission orders included Neurology consultation, eye ointment, routine vital signs, and regular diet. The consultation was completed, noting left eye increased blink rate, lower motor neuron right facial weakness (forehead, eyelid, mouth), and 3+/3+ suprapatellar reflexes. 

The patient was diagnosed with right Bell's Palsy. Recommendations included CT (computed tomography) angiogram of the neck, a seven-day course of prednisone, seven-day course of Valtrex, additional labs, eye protection including coverage at night. The CT (computed tomography) angiogram was normal. He was started on both prednisone and Valtrex as well as eye drops and eye protection during sleep. 

The patient was deemed stable for discharge with close outpatient follow-up. 

No, the Inpatient admission was not medically necessary. The patient could have been safely managed at a lower level of care. 

Bell's palsy is a unilateral facial nerve paresis or paralysis of unclear etiology most commonly seen in people ages 15 to 40 years. Recovery is typically spontaneous within a month, but up to a third of patients may experience incomplete recovery. A certain percentage of cases have been attributed to re-activation of herpes virus dormant in the facial nerve. There is a slightly higher incidence in pregnant women. In addition to palsy, patients may complain of mild pain in or behind the ear, oropharyngeal numbness, altered tolerance to noise, and altered taste on the anterior part of the tongue. Severe pain is more likely due to herpes zoster virus infection. There are a number of intervention strategies, including corticosteroids and antiviral agents. 

In this case, the patient presented to the ED (emergency department) with signs and symptoms suggestive of Bell's palsy. CT (computed tomography) scan was unremarkable as was CT (computed tomography) angiogram. He was monitored overnight, with Neurology consultation and subsequent recommendation to treat with corticosteroids and antivirals. While it was not unreasonable to monitor him in the hospital for alteration in symptoms while completing the evaluation, he was overall neurologically and hemodynamically stable and did not require acute inpatient admission. He could have been safely managed with a lower level of care such as observation.