Appeal type: Medical necessity
Decision: Upheld

Diagnosis: left-sided weakness and chest discomfort
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

This is the case of a male with a history of hyperlipidemia and obesity who presented to the emergency room (ER) complaining of left-sided weakness and chest discomfort. A computed tomography angiography (CTA) of the head was unremarkable, but computed tomography (CT) angiogram revealed a 4-millimeter (mm) aneurysm at the basilar tip. He was subsequently admitted to the stroke unit with concerns for transient ischemic attack. Aspirin (ASA) 325 mg was administered immediately (STAT), neurochecks were done every 2 hours, and magnetic resonance imaging (MRI) of the head was relatively insignificant. The patient passed the dysphagia screen, and he was given acetaminophen for complaints of headache. Additional laboratory test was remarkable for cholesterol at 219 and low-density lipoprotein (LDL) cholesterol at 141. The correspondence note stated that admission is indicated for 1 or more of the following to include vital signs, neurologic signs, or vascular checks more frequently than every 4 hours. The patient was subsequently discharged with all symptoms having resolved. The inpatient stay was denied indicating that the inpatient care was not medically necessary. The denial was appealed. 

According to the Milliman Care Guidelines (MCG), indications for admission to inpatient care for patients who may be having an ischemic stroke include that the patient has 1 or more of the following to include initial institutes of health stroke scale score greater than 2, evidence of hemorrhagic transformation, altered mental status, findings that warrant inpatient physical or occupational therapy treatment or evaluation, dysphagia that warrants evaluation, significant arm or leg weakness, aphasia, gait impairment, finding on brain imaging that requires inpatient care to include mass, edema, or large acute infarction, or if clinical stability is unclear such as recurrent or worsening findings.  When there is a clinical need for inpatient care monitoring, 1 more the following must be present to include hemodynamic instability, cardiac arrhythmias of immediate concern, clinically significant cardiac or vascular disorder identified that requires inpatient care to include severe valvular disease, atrial myxoma, or arterial dissection for example. Also, when the patient had respiratory abnormalities, severe hypertension, prolonged cardiac telemetry monitoring needed, suspected vasculitis, or pregnancy. Inpatient care may also be needed if there is embolic etiology of stroke suspected and inpatient anticoagulation is needed. 

The information provided for the review did not support that the patient met the criteria for admission to inpatient care. Alternatives to treatment could have been utilized to include outpatient evaluation and treatment in the emergency department, rapid treatment site, urgent care center, or medical office. Given that the same alternative care planning recommended by the MCG could be implemented on an outpatient basis order an observational basis, the inpatient care was not a medical necessity based upon the provided information. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for an inpatient admission is upheld. Medical Necessity is not substantiated.