Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Unilateral leg pain and weakness

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

 
This case involves a patient who presented to the hospital.  There was a history of obesity, diabetes mellitus, tobacco use, hypertension, prostate cancer, and cerebrovascular accident.  The patient presented with right-sided weakness that started 15 minutes prior.  The patient developed right-sided arm and leg weakness and associated numbness.  The symptoms had been intermittent for 2 days but became constant that day.  The patient reported severe back pain and multiple neurological symptoms in the past few weeks.  Vital signs of the patient were documented as blood pressure 157/117, temperature of 98.3 (degree) Fahrenheit, pulse of 80, respirations of 20, and oxygen saturation of 100% (percent) on room air.  The patient rated the pain 8 out of 10.  On exam, the patient appeared comfortable.  The patient was not ill or toxic appearing.  There was weakness present.  The patient had chronic left-sided facial droop.  The patient walked with a limp and dragged the right side.  The patient had decreased strength in the left upper extremity and left lower extremity with decreased sensation on the left side.  There was consideration for acute coronary syndrome, electrolyte disturbance, and transient ischemic attack versus cerebrovascular accident.  Neuroscience recommended admission for magnetic resonance imaging.  Imaging and laboratory work-up showed no acute findings.  The patient's white blood cell count was 7.1, hemoglobin was 12.6, hematocrit was 37.9, and creatinine was 1.07.  An electrocardiogram noted normal sinus rhythm and nonspecific T wave (interval on EKG [electrocardiogram]) abnormality.  The patient was given acetaminophen and ketorolac.  Magnetic resonance imaging of the brain did not show acute cerebrovascular accident.  Computed tomography angiography of the head and neck as well as computer tomography (CT) of the head did not show any large vessel occlusion.  

It was stated that the inpatient hospital admission was not considered medically necessary as per Milliman Care Guidelines (MCG) stroke guidelines.  The patient did not have neurological findings that warranted inpatient care.  The patient could have been placed in observation under monitoring, had an evaluation, had testing completed, and been treated symptomatically while awaiting test results.  Consultation with other professionals could have been done in observation.  There was no hemodynamic, pulmonary, neurological, or metabolic reason for acute level of care.

Per the cited references, admission for suspected transient ischemic attack is indicated for patients with hemodynamic instability that persists despite appropriate treatment, when focal neurological signs recur, when there are findings on brain imaging that requires inpatient care, when there is altered mental status, when there cardiac arrhythmias of immediate concern, when clinically significant cardiac or vascular disorder is identified, for severe hypertension with systolic blood pressure greater than 180 or diastolic blood pressure greater than 120, when prolonged cardiac telemetry monitoring is needed beyond observation care timeframe, for suspected vasculitis, and when parenteral anticoagulation is required.  In this case, the patient presented to the hospital with acute right-sided arm and leg weakness.  The patient had a history of prior cerebrovascular accident with chronic left-sided weakness.  Initial diagnostic work-up had been unrevealing.  The documentation did not support that the patient had failed observation level of care or had acute indications for inpatient level of care. 

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 inpatient hospital admission is not substantiated.