Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rule out acute ischemic stroke
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld.

This case involves an adult who was seen in the emergency department (ED) claiming to have muscle weakness and aches and reported 6/10 pain for 1 day. Her Glasgow Coma Score is 15 and she had a past medical history significant for transient ischemic attack/mild stroke. Upon arrival, the patient had a steady gait, was calm/cooperative, and claimed to not feel right. She complained of a headache, numbness to the lips, and was noted to have left-sided facial droop.  She moves all extremities with equal strength and strong bilateral grip. The remainder of her assessment was unremarkable.  The patient was subsequently admitted to telemetry for further work-up. Her lower lip numbness from the night before had resolved and she had intermittent change in vision, paresthesias to both hands and left leg along with nausea. At the time of assessment, she denied having any of the symptoms. She appeared to be in mild distress but was alert and oriented to person, place, time, and situation. Her neurological assessment noted only the minor paralysis of the nasolabial fold and asymmetry on smiling.  She otherwise had no other symptoms of a stroke. The attending physician thought the patient may be having a transient ischemic attack. The patient remained on inpatient status. Computed tomography (CT) of the head was relatively normal.  She was prescribed aspirin 81 milligrams (mg) to be taken orally daily along with metoprolol extended release (ER) 25 mg to be taken orally daily. The patient was discharged the following day in stable condition.  

According to the Milliman Care Guidelines, clinical indications for admission to inpatient care for an individual suffering acute ischemic stroke must include one more the following to include either that the patient has a National Institutes of Health Stroke Score (NIHSS) greater than 2, evidence of hemorrhagic transformation, altered mental status, dysphagia that warrants evaluation, significant arm or leg weakness, aphasia, gait impairment, finding on brain imaging that requires inpatient care, or clinical stability is unclear (recurrent or worsening findings). The guidelines also indicate that inpatient care may be indicated if the patient is hemodynamically unstable, has cardiac arrhythmias of immediate concern, has clinically significant cardiac or vascular disorders identified that requires inpatient care, has respiratory abnormalities, severe hypertension, prolonged cardiac telemetry monitoring needs, suspected vasculitis, or they are pregnant. Also, if the patient has a planned or recently performed thrombolysis or requires urgent inpatient procedures such as thrombectomy, then inpatient care may be warranted.  

However, the information provided for the review did not support that the patient met any of these criteria. Other than the flattened nasolabial fold on the left side while smiling, her NIHSS score was 1 with no other findings indicating significant neurological abnormalities to justify the inpatient care. She could have had her care and further work-up administered safely and effectively on an outpatient or observational basis.  

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient admission is not substantiated.