Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems-Stroke/CVA
Treatment: Inpatient Hospital stay
The Health Plan denied the inpatient stay as not medically necessary. 
The reviewer has overturned in whole the health plan's determination. 

The patient has a history of sickle cell disease/anemia, pulmonary embolism (PE), on anticoagulation, cerebrovascular accident (CVA) and transient ischemic attack (TIA). She presented with acute onset right sided weakness. She also developed left eye blurriness and had weakness of the right side. In the emergency department she was tachycardiac with a heart rate (HR) of 100. Her blood pressure was 145/78. Her respiratory status was normal, and she was saturating 100 per cent (%) on room air (RA). She had right sided weakness. That was new from her baseline. Her labs showed anemia with hemoglobin (Hb) of 8.8 and an elevated reticulocyte count of 7%. Due to concern for an acute stroke, a stroke code was called. She was given intravenous (IV) pain medications and IV hydration. She was evaluated by neurology and hematology and oncology. Supportive care was suggested by hematology. Neurology recommended a full stroke work up including magnetic resonance imaging (MRI) of the brain. The patient was deemed not a candidate for thrombolysis due to ongoing anticoagulation. She was admitted, placed on telemetry, continued IV hydration and pain medications. She was required frequent pain medications. She did not complete the full stroke work up and subsequently decided to leave against medical advice.

The inpatient stay was medically necessary.
The patient, with a complex past medical history of sickle cell disease, veno-occlusive disease, multiple hospital admissions, TIA, and CVA, who presented with new onset of neurological symptoms and pain. She was hemodynamically stable but had mild tachycardia and mildly elevated blood pressure. She had right sided weakness and visual blurriness. She was anemic with an elevated reticulocyte count. She was thought to have an acute stroke and a code stroke was called. The patient was a very high-risk patient due to her history of stroke and TIA. From her history of sickle cell disease, veno-occlusive disease, and new neurological symptoms, as well as anemia with elevated reticulocyte, there was a concern for sickle cell crisis. The neurological symptoms are common manifestations of the sickle cell crisis and can be seen in 80 - 90% of the patients. There is a high risk of morbidity. Therefore, prompt evaluation is recommended [1,2]. Her (Age, Blood Pressure, Clinical Features of TIA, Duration, Diabetes) ABCD2 score was 5 points with 2-days stroke risk of 4.1%. due to elevated blood pressure, unilateral weakness, and symptoms greater than (>) 60 minutes [3]. These findings made her a very high-risk patient that demanded inpatient evaluation and treatment.
Per Milliman Care Guidelines (MCG) Health Inpatient & Surgical Care 25th Edition Stroke: Ischemic, the inpatient admission was indicated due to the presence of neurological symptoms, including unilateral weakness as well as visual changes [4]. She required telemetry monitoring and further imaging. MRI is the gold standard to diagnose stroke. Unfortunately, the patient left against medical advice (AMA) before completion of her work up, however she certainly met the criteria for inpatient admission.