Appeal type: Medical necessity
Decision: Upheld

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

The insurer denied inpatient hospital admission for medical necessity. 
The denial was upheld. 

The patient is a male with a past medical history of hypertension, coronary artery disease (CAD), renal cancer status/post (s/p) nephrectomy, who presented to the Emergency Department with right upper extremity weakness and numbness. The patient had a history of cervical spine surgery where the "surgeon messed up his spine." He had been taking aspirin and Plavix. There were no reports of change in mental status, slurring of speech, blurring of vison, nausea, vomiting, fever, cough, abdominal pain, chest pain, shortness of breath, or any urinary or bowel disturbances. 

His initial vital signs were a blood pressure (BP) of 162/93, respiratory rate (RR) was 20, heart rate (HR) was 76, temperature (T) was 98.7 F and pulse oxygen saturation (SpO2) of 97% on ambient air. His laboratory findings were as follows, a white blood cell count (WBC) of 7.8 K, hemoglobin level of 15.5 g/dl, sodium was 136, potassium was 4.3, glucose was 85 mg/dl, blood urea nitrogen (BUN) was 12, and creatinine was 1.3. 
His electrocardiogram (EKG) was normal sinus rhythm. The neurologic exam showed no focal deficits. His chest x-ray showed no active pulmonary disease.  A computed tomography (CT) scan of the brain without contrast showed no acute intracranial findings. A computed tomography angiography (CTA) of the head and neck were within normal limits. A progress note stated that the patient had chronic extremity weakness. The patient declined a brain magnetic resonance imaging (MRI). 

The patient was treated with aspirin and Plavix, monitored without any events, and was discharged in stable condition. 

At issue is the medical necessity of an inpatient hospital admission.

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

The inpatient stay was not medically necessary. 

There was no evidence that the patient succumbed to a complete acute ischemic or hemorrhagic stroke. Neurology was consulted; however, consultation notes did not determine or document that the patient had an acute stroke. An MRI was not able to be performed because the patient had refused. The patient was hemodynamically stable without acute respiratory failure or altered mental status and had no persistence or recurrence of focal neurologic signs and symptoms. The patient did not have severe uncontrolled hypertension. He did not have suspected embolic source (i.e. atrial fibrillation) requiring parenteral anticoagulation or any alternative forms of rapid anticoagulation due to contraindication to unfractionated heparin. There was no evidence of severe valvular disease, atrial myxoma, cardiomyopathy or any cardiac arrhythmias of immediate concern. 

The age, blood pressure, clinical features and duration (ABCD) score of 5 put the patient at a moderate risk for stroke, and warranted hospitalization for Neurology consultation and an expedited timely diagnostic work up, but this did not entail acute inpatient admission. The intensity and level of care for this patient was not high. The patient had history of cervical spine surgery and had admitted to having chronic extremity weakness.
Therefore, the inpatient stay was not medically necessary. The patient could have been treated at a lower level of care status.