Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stroke
Treatment is an inpatient admission
The insurer denied coverage for an inpatient admission
The denial is upheld.

This is a patient with a history of hypertension and cerebrovascular accident. The patient presented to the hospital and reported a 2-day history of dizziness, headaches, and right vision loss. Blood pressure ranged from 133/84 to 167/92, pulse was 63-71, and respiratory rate was 23-27. On exam, there was a right temporal visual field cut. The patient's white blood cell count was 12.2 with a hemoglobin of 15.3 and hematocrit of 46.7. A computed tomography of the head revealed a subacute left posterior cerebral artery territory infarct. There were multiple chronic infarcts. An electrocardiogram revealed sinus bradycardia. Later, it was noted that the patient had no abnormality in their heart rhythm. The patient was discharged with a follow-up with the primary care provider and cardiologist.

It was argued that the inpatient hospitalization was medically necessary. A summary of the patient's hospital course was detailed. Due to concern for arrhythmia and potential for progressive cerebrovascular decline, the patient was judged as clinically unfit for discharge requiring inpatient treatment and care not available at a lower care setting. The patient required telemetry for close monitoring, neurovascular checks, aspirin, Lipitor, and home medications. The suggestion of another cerebrovascular accident was concerning and considered dangerous in a less acute setting. As such, the admission was medically necessary.

Per the MCG (Milliman Care Guidelines), hospital admission is warranted for stroke and the patient has a National Institutes of Health Stroke Scale (NIHSS) score greater than 2, evidence of hemorrhagic transformation, altered mental status, dysphagia, significant arm or leg weakness, aphasia, gait impairment, findings on brain imaging that require inpatient care such as mass, edema, or large acute infarction, or for clinical instability. It may also be recommended when thrombolysis is going to be performed or is planned or when an urgent inpatient procedure was planned.  

In this case, the patient presented to the hospital with complaints of dizziness, headache, and right vision loss. Computed tomography of the head revealed a subacute left posterior cerebral artery territory infarct. There were multiple chronic infarcts. It was argued that the inpatient hospitalization was medically necessary. The patient required inpatient treatment and care not available at a lower level. However, the documentation did not detail that the patient had evidence of hemorrhagic transformation, altered mental status, dysphagia, significant arm or leg weakness, aphasia, gait impairment, findings on brain imaging that required inpatient care such as mass, edema, or large acute infarction, or clinical instability. The documentation also did not detail that there was a plan for thrombolysis. In addition, contrary to the appeal letter, this was not an acute event and assessment for an arrhythmia is done as an outpatient. His NIHSS score was 1. As such, the denial of coverage for inpatient hospitalization was appropriate and is upheld.

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

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