Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multiple Sclerosis
Treatment: Inpatient Hospital Services
The insurer denied coverage for inpatient hospital services
The denial is overturned.

This case involves a female who presented to the emergency department (ED) complaining of 1 month of blurry vision of the left eye, numbness of the left arm and leg, which worsened over the past week, with a history of unspecified headaches. The patient had been sent to the ED by her ophthalmologist who recommended she be seen by a neurologist. When she was unable to get an appointment with a neurologist, her primary care physician recommended she come to the ED. She endorses photophobia but no phonophobia. Advil provided no relief. Vital signs were relatively stable, but she had decreased vision throughout the left visual fields. Sensation was 4/5 for the left upper and lower extremities. Laboratory testing was conducted with plans to obtain magnetic resonance imaging (MRI). MRI of the brain showed innumerable enhancing T2 (transverse relaxation time) foci of hyperintensity in the supratentorial and infratentorial white matter, most likely demyelinating disease, to include multiple sclerosis, with very remote possibility of infectious or neoplastic disease with notation that the patient had a history of Coronavirus disease 2019 (COVID-19) viral infection. Magnetic resonance angiography (MRA) of the brain without contrast showed no evidence of proximal branch occlusion or high-grade proximal stenosis to the visualized vessels of the circle of Willis. Diagnoses at that point time included the headaches, paresthesia, and loss of vision in the left eye. 

The patient's vital signs and neurological status were monitored. She remained on observational status throughout those 2 days. A decision was made to upgrade the patient to inpatient status for close neurological monitoring. She continued to have tingling to the left upper and lower extremities along with left dorsal tightness, blurry vision, and visual impairments. MRI of the cervical spine and thoracic spine with contrast showed demyelinating disease. Lumbar puncture showed no evidence of viral or bacterial meningitis, with protein elevated consistent with multiple sclerosis. The plan was to place the patient on high-dose intravenous Solu-Medrol. The patient remained on inpatient status until she was discharged with improved vision and paresthesia. 

According to the Milliman Care Guidelines (MCG), clinical indication for admission to inpatient care may include patients who have neurological findings such as new onset of paralysis. When the patient presented, she endorsed one month of blurry vision in the left eye and numbness of the left arm and leg that became acutely worse over the week prior to her admission. The MRI obtained identified demyelinating brain lesions, likely multiple sclerosis. The patient was otherwise afebrile and hemodynamically stable. However, given her visual impairments and new onset of neurological deficits, she met the criteria for inpatient care. Once she showed a response to the Solu-Medrol, she was safe for discharge to be followed up by her primary care physician and a neurologist. 

After a review of the provided documentation and in reference to the MCG, it was determined that the patient met criteria for inpatient care and the treatment rendered was reasonable and within standard of care.  

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient hospital services is overturned. Medical Necessity is substantiated.