Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld in whole.

The patient is a female with a past medical history significant for hypertension, hyperlipidemia, cerebrovascular accident (CVA) associated with residual right leg weakness, previous history of brain aneurysm surgery, and hysterectomy who presented to the emergency department according to the recommendation of her cardiologist for evaluation of chest pain.
In the emergency department, the patient was afebrile, heart rate was 67 beats per minute (bpm), blood pressure 178/84, respiratory rate 16, oxygen saturation within normal limits.
On the physical exam, the patient was awake, alert, in no acute distress. Her skin was warm and dry without cyanosis or rash. The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. The neck was supple without lymphadenopathy, masses, jugular vein distention (JVD), carotid bruits. Lungs were clear to auscultation without wheezes, rales, or rhonchi. The patient had a regular rate and rhythm, without murmurs, rubs, or gallops. The abdomen was soft, nontender to palpation, with normal bowel sounds, without guarding or rebound.
The patient had tenderness to palpation in the right upper inner thigh without erythema, swelling. The patient had normal distal pulses. The neuro exam was unremarkable.
Laboratory evaluation revealed that white blood cell count was 7.66, hemoglobin 12.1, hematocrit 37.9, platelets 224. Sodium was 144, potassium 4.0, chloride 106, bicarbonate (HCO3) 28, blood urea nitrogen (BUN) 16.6, creatinine 1.06, glucose 115.
Electrocardiogram (EKG) showed normal sinus rhythm, 79 bpm, normal axis, no acute ischemic changes. A chest x-ray revealed no focal consolidation or any other acute changes. Computed tomography (CT) scan of the head demonstrated chronic infarcts. There were no acute changes.
The patient was admitted to the hospital for evaluation of headache and possible left-sided stroke. In the hospital, the patient was seen by a neurologist who stated that the patient underwent an MRI(Magnetic resonance imaging) of the brain that demonstrated subacute/chronic strokes. There was no evidence of acute stroke or a recurrent aneurysm. During the hospital stay the patient was restarted on her blood pressure medications, aspirin. The headache resolved. The patient was discharged home with home physical and occupational therapy. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld in whole.

During the entire hospital stay the patient remained hemodynamically stable, had an unremarkable neurologic exam, with the neurologic deficits being related to a previous stroke. There was no evidence that the patient had new neurologic deficits. There was no evidence that the patient had altered mental status, cardiac arrhythmias of immediate concern, a clinically significant cardiac disorder such as severe valvular disease, cardiomyopathy, or severe hypertension that could not be managed at a lower level of care status.
This patient did not require any inpatient procedures or surgeries such as endarterectomy, she did not need parenteral anticoagulation or administration of parenteral antiplatelet agents. Overall, she remained in stable clinical condition. Therefore, the admission could have been managed at a lower level of care in order to determine if the patient in fact had a new stroke, and to get the blood pressure under better control.