Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Possible stroke

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld
 

The patient presented to the emergency room with complaints of dizziness x 2 hours, right arm pain x 3 days, denies room spinning. Upon assessment, the patient was unable to feel his right arm and was unable to keep the right arm elevated secondary to pain. He reports his dizziness is making him feel off balanced. Stroke code called in triage. Computed tomography (CT) was performed and imaging results noted non-hemorrhagic and no acute findings. No evidence of large acute territorial infarct or acute intracranial pathology. ABCD2 (estimates risk of stroke) score of 3. Etiology more likely due to peripheral cause such as cervical radiculopathy, can rule out central cause such as ischemic stroke. The patient reported having a history of a bad neck and right-sided neck pain. He does have moderate to severe spinal canal narrowing. Neurosurgery was consulted for care as patient may have radiculopathy or brachial plexus issue. Provider notes patient will require magnetic resonance imaging (MRI) as an inpatient and given severity of arm symptoms, will admit for MRI. Duplex of right upper extremity showed normal arterial flow. A cervical MRI showed multilevel severe spinal stenosis with degrees of cord compression. Cervical (C)3-4 disc herniation compressing the cord. C4-5 disc herniation with posterior hypertrophic changes compressing the cord. C5-6 with moderate spinal stenosis and disc bulging. C6-7 with mild spinal stenosis and disc bulging. MRI of the brain showed no evidence of acute infarct, intracranial hemorrhage, mass effect, or midline shift. An x-ray of the right elbow showed no evidence of acute fracture or dislocation. No elbow joint effusion. There is mild degenerative change of the elbow. X-ray of the right shoulder showed no evidence of acute fracture or dislocation. There is severe degenerative change of the acromioclavicular (AC) joint and mild degenerative change of the glenohumeral joint. 

Milliman Care Guidelines (MCG) notes observation status is indicated for patients with weakness, dizziness, and pain that requires additional testing, monitoring, or treatment beyond the emergency department timeframe. An inpatient admission is required for a neurologic condition, symptom, or finding for which observation care has failed or is not considered appropriate. 

The review of clinical records and care guidelines found the inpatient admission was not medically necessary. This patient could have been placed in observation status. If MRI was needed and the symptoms were so severe, it could have been performed without delays after presentation. After initial testing ruled out stroke, observation status would have been sufficient, and the patient could have received any additional testing as an outpatient. The acute hospital admission was not medically necessary for this patient. 

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 the inpatient admission is not substantiated.