Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

The patient is a male with a history of hypertension, diabetes mellitus, hyperlipidemia, schizophrenia, and substance abuse. He reported that he last utilized cocaine 5 days prior. The patient reported dizziness and facial droop for two days. He was admitted 2 days prior for the same symptoms. His initial computed tomography (CT) and angiography were negative. He left against medical advice (AMA). The patient endorsed persistent/worsening symptoms and returned for further work-up. His review of systems was positive for dizziness, facial asymmetry, and speech difficulty. The vital signs of the patient noted a blood pressure of 124/76, pulse of 70, temperature of 98.5 Fahrenheit, and respirations of 16. The patient was nontoxic appearing. There was a cranial nerve deficit with abnormal gait. The left nasolabial fold was smoother than the right. His speech was clear. There was no ptosis. The patient was able to lift the bilateral upper extremities against gravity without drift. The neurological exam was virtually unchanged from the previous day. He endorsed unsteady gait, facial asymmetry, and speech difficulty. There was a plan to admit for further work-up. It was noted that the patient was previously admitted for dizziness and falls the previous year. His bubble study had been positive at that time. The patient had magnetic resonance imaging (MRI) which did not demonstrate any acute intracranial process. As per neurology, his weakness was likely related to transient neurological deficit in the setting of cocaine use. Psychiatry was called for optimization of the patient's psychiatric medications. He was assessed by rehabilitation and was deemed independent to ambulate with no apparent need for physical therapy. The patient left AMA.

Per InterQual, for patients suspected of TIA (transient ischemic attack), the documentation should identify neurological deficits and high-risk factors including crescendo TIA, endocardial vegetation by echocardiogram or MRI, or previous stroke. The MCG (Milliman Care Guidelines) notes that admission may be indicated for those with hemodynamic instability, recurring focal neurological signs, altered mental status, cardiac arrhythmias, when an urgent inpatient procedure is planned, or when parenteral anticoagulation is required. A history and physical examination, laboratory and diagnostic testing, and outpatient antithrombotic therapy can be completed an observation level of care.

In this case, the patient presented to the hospital with dizziness and facial droop for two days. He had a history of hypertension, seizures, diabetes mellitus, hyperlipidemia, schizophrenia, and substance abuse. He reported recent cocaine use. His exam noted facial asymmetry and an unsteady gait. It was argued that the patient met MCG criteria for admission. The patient was admitted to rule-out acute CVA (cerebral vascular accident)/TIA. The patient required very close monitoring which could not be completed in the outpatient setting. However, the patient's care could have been completed at an observation level of care. The patient's symptoms were largely unchanged from the previous assessment that occurred 2 days prior. Initial work-up had been non-diagnostic. His MRI did not demonstrate any acute intracranial process. The documentation did not identify hemodynamic instability, changes neurological signs, or an altered mental status.

As such, the inpatient hospital admission was not medically necessary.  

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

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