Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right-sided Weakness

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

The patient presented to the hospital.  The patient had a history of hypertension, hyperlipidemia, diabetes mellitus, prior cerebrovascular accident with residual left face and upper extremity tingling/numbness, and substance use disorder including alcohol and marijuana.  The patient stated that 3 days prior, they developed right-sided weakness and tingling sensation.  The patient was able to move the right upper and lower extremity normally.  The patient was able to ambulate.  The patient had full sensation, no facial droop, no slurred speech, and no gait abnormality.  The patient was concerned that they had another stroke.  The review of systems was positive for weakness.  The patient was outside of the window for any intervention.  There was a plan for computed tomography (CT) of the head and laboratory testing.  Vital signs of the patient noted blood pressure of 149/79, heart rate of 117, respiratory rate of 18, and temperature of 98.1 Fahrenheit.  The physical exam findings were unremarkable.  The patient was admitted with impression of left cerebrovascular accident.  The patient's troponin and B-type natriuretic peptide (BNP) were normal.  Electrocardiogram showed sinus tachycardia, left atrial enlargement, and T wave inversions in the inferior leads.  A computed tomography (CT) of the head without contrast showed chronic lacunar infarct on the left.  A CT angiogram of the neck and head showed atherosclerotic disease involving the right and left cavernous internal carotid artery which caused mild to moderate narrowing.  Magnetic resonance imaging of the brain showed small acute to subacute lacunar infarct of the left thalamus. The patient was advised that they required an echocardiogram for complete work-up of source of thrombus.  However, the patient walked out of the hospital while the team was rounding and could not be reached when staff attempted to call them to return.    

Per the cited references, admission to the hospital for acute stroke with neurological findings is supported when there is altered mental status, dysphagia that warrants evaluation, significant arm or leg weakness, aphasia, gait impairment, finding on brain imaging that requires inpatient care such as mass, edema, or large acute infarction, or when clinical stability is unclear.  In this case, the patient was admitted to the hospital with suspected stroke. Magnetic resonance imaging noted small acute to subacute lacunar infarct of the left thalamus.  It was argued that full inpatient admission was medically necessary for the patient due to the need for evaluation of acute cerebrovascular accident.  However, the documentation did not identify altered mental status, dysphagia that warranted evaluation, significant arm or leg weakness, aphasia, gait impairment, finding on brain imaging that required inpatient care such as mass, edema, or large acute infarction, or that clinical stability was unclear. The patient's monitoring, diagnostic evaluation, and treatment could have been conducted at a lower level such as observation level of care.  As such, the health care plan acted reasonably, with sound medical judgement, and in the best interest of the patient.  

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 the inpatient admission is not substantiated.