Appeal type: Medical necessity
Decision: Upheld

This is a patient with a past medical history significant for hepatitis C who presented to the emergency department with complaints of a right facial droop and left upper extremity numbness that he described as a pins and needles sensation.
His symptoms started on the day of admission but he was still able to go to work and worked the entire shift. The patient stated that in the last several months that preceded the day of admission he had a weird sensation when he would come in from the outside. While indoors, he started to experience severe back stiffening, chest tightening, and difficulty breathing. This prompted the patient to use an air conditioner even during the wintertime and take cold showers.
Reportedly, on the day of admission, the patient picked up an overtime shift and took the subway to go to work. While on the subway, the patient started to experience profound malaise and intermittent left upper extremity numbness, pins and needles sensation, as well as extreme chest/back tightness and difficulties, breathing. This prompted the patient to look for a police officer who dispatched an ambulance for him.
In the emergency department, the patient was suspected to have a possible stroke. The National Institute of Health Stroke Scale (NIHSS) was calculated at 4. No tissue plasminogen activator (TPA) was given. At the time of admission, the patient was afebrile, his pulse rate was 70 beats per minute (bpm), blood pressure was 134/95, respiratory rate 16, and oxygen saturation 100% on room air.
The patient was lying comfortably in bed, in no acute distress. His head, eyes, ears, neck, throat (HEENT) exam was within normal limits. The neck was supple, with no jugular vein distention (JVD). The respiratory exam showed that the lungs were clear to auscultation, the cardiac exam was within normal limits. The gastrointestinal (GI) exam was unremarkable.
On the neurological exam, the patient was awake, alert, and oriented times () 3. His speech was fluent, he had intact naming, repetition, and comprehension skills. There was no dysarthria. The recent and remote memory were intact. The patient was able to follow commands.
The patient had a right facial droop. The muscle strength was normal in the upper and lower extremities. Sensation to light touch was normal bilaterally. There was no neglect. There was no evidence of dysmetria or pathologic reflexes. Laboratory evaluation revealed that the patient's white blood cell count was 6.65, hemoglobin 14.6, hematocrit 42.9, and platelets 302. Sodium was 135, potassium 3.7, chloride 100, bicarbonate 23, blood urea nitrogen (BUN) 16, creatinine 1.1, and glucose 86. Liver function tests were within normal limits.
An electrocardiogram (EKG) revealed normal sinus rhythm, 70 beats per minute (bpm), and no evidence of ischemia.
A computed tomography (CT) scan of the head demonstrated a wedge-shaped area of hypodensity within the left frontal lobe without mass effect or adjacent dilatation that most likely represented an old infarct. A CT angiogram demonstrated no carotid stenosis or large vessel occlusion.
The patient was admitted to the hospital to rule out a cerebrovascular accident (CVA).
A magnetic resonance imaging (MRI) scan of the brain was performed and demonstrated multiple foci of chronic small vessel ischemic changes bilaterally. There was no evidence of an acute stroke. At the time of admission, the patient was suspected to have chronic obstructive pulmonary disease (COPD), therefore, he was recommended for an outpatient workup including Pulmonary Function Tests (PFTs).
In the hospital, the patient was seen by a neurologist. According to the neurologist, the patient had no neurologic deficits noted on the exam except for right facial droop and subjective diffuse body decreased sensation to light/sharp touch. According to the neurologist, the patient reported experiencing similar symptoms in the past. The neurologist noted that the patient was very anxious, and his clinical presentation was most consistent with an anxiety disorder. The neurologist also noticed that the patient had pressure and tangential speech that was possibly associated with a panic type disorder. Even though the neurologist thought that multiple sclerosis was on the differential diagnosis based on the clinical symptoms, the MRI of the head was unrevealing and did not have lesions typical for multiple sclerosis (MS). According to the recommendations of the neurologist, the patient was started on Lexapro.
It was stated in the discharge summary that the acute stroke was ruled out and the patient was discharged home in stable clinical condition. At issue is the medical necessity of an inpatient stay.
The health plan's determination is upheld.  The inpatient hospital stay  was not medically necessary for this patient because of the mild severity of his symptoms, and lack of evidence that the patient had a serious medical condition requiring hospital stay at the acute inpatient level of care.
As was noted by the neurologist, the patient's symptoms were nonspecific and his neurological exam was unremarkable for the most part, except for the facial droop. The results of the laboratory studies and diagnostic tests did not reveal the presence of significant abnormalities including acute stroke, multiple sclerosis, or any other conditions. The patient's symptoms were attributed to anxiety and possible panic disorder, therefore the patient was started on Lexapro.
Taking into consideration all of this information, there was no overwhelming evidence that either the severity of the patient's condition or the complexity of the services provided rose to the level of an acute inpatient level of care. During the hospital stay the patient did not have any procedures that would necessitate admission at the acute inpatient level of care.
Therefore, care could have been provided at a lower level than inpatient to rule out an acute stroke and other potentially serious medical conditions.