Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vision. 
Treatment: Inpatient Hospital. 

The insurer denied Inpatient Stay. 
The denial is upheld. 

The patient is a male with a previous medical history significant for tobacco use, who presented to the emergency department with loss of vision out of the right eye. It was reported that the patient had blurry vision for approximately two weeks, but on the day of the presentation, the vision out of the right eye significantly worsened. The patient denied any associated symptoms including headache, pain in the eye, dizziness, nausea, vomiting, hearing changes, speech changes, numbness, or weakness in his body. The patient denied recent head/neck trauma, car accident, neck manipulation, or fall. 
Upon initial evaluation in the emergency department, the patient underwent a computed tomography (CT) scan of the head which demonstrated left frontal encephalomalacia. The patient stated that he had a head injury when he was assaulted. Following the injury, the patient developed epilepsy. He took antiseizure medications for a while but had not had a seizure for at least 10 years. Subsequently, the patient underwent a CT angiogram of the neck which revealed bilateral internal carotid artery stenosis with right side stenosis/plaque next to the ophthalmic artery. 

The neurologic exam was completely normal except for the presence of monocular right eye vision loss. The laboratory evaluation revealed that sodium was 140, potassium was 4.0, chloride was 107, bicarbonate was 17, blood urea nitrogen (BUN) was 8, creatinine was 0.7, and glucose was 186. His alanine aminotransferase (ALT) was elevated at 110, alkaline phosphatase was 113, and total bilirubin was 1.2. 

The patient was admitted to the hospital. It was determined that he was not a candidate for tissue plasminogen activator (tPA). He was not a candidate for thrombectomy. In the hospital, he was seen by a neurologist who recommended workup for a possible stroke including a magnetic resonance imaging (MRI) of the brain. Subsequently, the MRI of the brain was performed and demonstrated no significant abnormalities. The patient was also seen by an ophthalmologist who suggested that the patient had vision loss in the right eye that could be related to a white cataract. There was no need for acute ophthalmologic intervention, and the patient was recommended to follow up with an ophthalmology clinic. The differential diagnosis of the patient's vision loss included central retinal artery occlusion or central retinal venous occlusion. Although, the presence of cataracts also could explain the symptoms. 

At issue is the medical necessity of the Inpatient Stay. 

The health plan's determination of medical necessity is upheld in whole. 

The requested health service/treatment of Inpatient Stay was not medically necessary for this patient. 

The differential diagnosis of the patient's symptoms included cataract versus central retinal artery occlusion or central retinal venous occlusion. The treatment of cataracts did not require admission at the acute inpatient level of care. There was no evidence that the patient had symptoms of an acute stroke based on the MRI. The vision loss was the only symptom. This was not associated with an altered mental status or other symptoms of possible stroke such as dysphasia, aphasia, significant gait impairment. There was no evidence of hemodynamic instability, respiratory abnormalities, or suspected vasculitis. The patient did not need any interventions or procedures requiring admission at the acute inpatient level of care. 

The patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. 
Therefore, the requested health service/treatment of Inpatient Stay was not medically necessary.