Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Stroke

Treatment hospital admission

The insurer denied coverage for hospital admission

The denial is upheld.

This patient has a history of hypertension as well as cholecystitis, dyslipidemia, and diabetes.  She was seen in the emergency department (ED) complaining of palpitations and weakness on the left side of her body for approximately 1 week.  She indicated she felt gradual onset, and leg weakness to the left detailing it started 1 week prior.  She also complained of being dizzy as well as lightheaded.  There was an associated headache.  Upon physical exam she had a temperature of 98.1 degrees Fahrenheit (F) with a pulse of 71 beats per minute (bpm).  Respirations are 17 breaths/min and oxygen saturation was 97% (percent).  Her blood pressure is 158/84 and she was noted to be alert and oriented to person, place and time.  Motor strength was 5/5 to the right upper extremity and right lower extremity and 4/5 to the left upper and lower extremity.  Sensation was intact.  It was recommended she be admitted to rule out a cerebrovascular accident (CVA).  Laboratory diagnostic studies were ordered.  A computed tomography (CT) scan of the brain revealed no acute process.  There was a small quantity of fluid or mucosal thickening to the right maxillary sinus.  A chest x-ray revealed no acute disease.  An electrocardiogram (EKG) revealed normal sinus rhythm at 68 bpm (beats per minute).  The documentation indicated she continue treatment and an magnetic resonance imaging (MRI) of the lumbar spine noted questionable subtle lower thoracic cord edema versus artifact from volume averaging.  A thoracic MRI was recommended.  She also underwent an echocardiogram revealing an ejection fraction of 60-65% with a dilated left atrium.  There was mild tricuspid regurgitation.  The submitted documentation indicated she was noted to have a probable acute on chronic lacunar stroke with left hemibody deficits on examination.  However, the CT scan as noted above showed no acute process.  The recommendation was made to undergo a physical therapy evaluation prior to discharge.  Additionally, it is noted urinalysis showed positive nitrate with white blood cells 6-10 epithelial cells 11-20 with moderate bacteria.  Her urine culture did grow Escherichia coli (E. coli)  and she was initiated on ceftriaxone however this was eventually changed to nitrofurantoin.  The documentation does detail she continued with treatment and no adverse events throughout the entirety of the stay.  She was discharged.

The patient presented to the ED with left-sided weakness along with palpitations. The patient was evaluated in the ED and admitted to the hospital. Imaging study of the brain via Head CT did not show an acute stroke. Patient was also treated with antibiotics for a urinary tract infection (UTI). EKG showed a normal sinus rhythm (NSR and echocardiogram was negative from the standpoint of thrombus. Care provided, including medical management, diagnostic imaging-including CT of the head and carotid Doppler ultrasound, and specialty consultation could have been provided at the level of the ED and at an observation level of care. Care provided did not warrant inpatient admission.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the hospital admission is not substantiated. The insurer's denial is upheld.