Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

The patient is a male with a past medical history significant for type II diabetes mellitus, hypertension, previous transient ischemic attacks (TIAs), anxiety disorder, alcohol dependence, vertebral artery stenosis, and restless leg syndrome who presented to the hospital with complaints of numbness and non-specific weakness of the face that he first noted one day before the admission. Reportedly, the patient was not feeling well for several days after he ran out of his Xanax and couldn't reach his primary care physician to renew his prescription. It was mentioned that the patient had elevated systolic blood pressure in the 180s associated with chest pressure.

The patient was admitted to the hospital with suspicion for withdrawal from benzodiazepines, also to rule out cerebrovascular accident (CVA).
The treatment with Xanax was resumed, and a magnetic resonance imaging (MRI) of the brain was ordered.
The MRI of the brain was performed and demonstrated no acute intracranial abnormality.
In the hospital, the patient was seen by a neurologist who doubted the diagnosis of stroke. However, because of the possible abnormalities seen on the computed tomography (CT) scan of the head, the patient was recommended an MRI of the brain and an echocardiogram. The neurologist also recommended treatment with aspirin, statin, and the resumption of Xanax.
During the hospital stay, the patient remained in stable clinical condition, therefore at the end of the hospitalization, he was transitioned to outpatient care.
The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care. Even though the patient had a TIA, there were no evidence of hemodynamic instability, persistent or recurrent focal neurologic signs. The neurologist who evaluated the patient in the hospital doubted the diagnosis of CVA. His symptoms were most likely related to anxiety in the setting of abrupt discontinuation of treatment with Xanax. The patient's neurologic exam was normal while seen in the emergency department and remained normal throughout the hospitalization.
There was no evidence that the patient had altered mental status, cardiac arrhythmias of immediate concern. There was no mention that the patient had clinically significant cardiac disorders such as severe valvular disease, atrial myxoma, cardiomyopathy, or hypertension that could not be controlled by the emergency department or at the observation level of care.
This patient did not require inpatient procedure or surgery such as endarterectomy, he did not need parenteral anticoagulation or administration of antiplatelet agents.
There is no evidence of how the severity of the patient's condition, or the complexity of services provided rose to the acute inpatient level of care.
Even at the time the patient was seen in the emergency department, he had an unremarkable neurologic exam.
Taking into consideration these facts, admission for monitoring was definitely indicated to rule out acute stroke, to ensure the patient did not have severe symptoms related to benzodiazepine withdrawal, and to perform the necessary workup that was indicated considering the clinical circumstances. However, the workup and clinical monitoring could have been performed at a lower level of care status.