Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Benzodiazepine withdrawal. 
Treatment: Inpatient stay. 
The insurer denied coverage for the inpatient stay. 
The denial is upheld. 

This is a patient who presented to the emergency room (ER). Complaints were of intermittent sensations that the patient's throat was closing 90% associated with shortness of breath and an unspecified "head sensation." The patient began speaking slowly and moving slowly at 3:00 AM that morning and was having trouble using the letter "R." The patient had stopped Xanax abruptly one week previously. The patient was found to be ambulatory with a steady gait and speaking clearly by Emergency Medical Services (EMS). The patient was noted to have a mild strength deficit on the left side. The patient had not slept in seven days. Examination in the emergency department revealed normal, speech/language, ear, nose, mouth, throat (ENMT), eye, cardiac, respiratory, gastrointestinal, musculoskeletal, examinations with a stroke scale score of 0, and normal skin and psychiatric examinations. A computed tomography (CT) scan of the head revealed no acute territorial infarct or hemorrhage. CT angiography of the head and neck was likewise negative. Differential diagnosis was stroke versus benzodiazepine withdrawal versus seizure. The patient was admitted to telemetry. Workup while hospitalized consisted of observation for benzodiazepine withdrawal. Aspirin was started and the patient was placed on neuro-checks. The patient was seen by neurology. A brain magnetic resonance imaging (MRI) was performed and was interpreted as no acute intracranial pathology. 

The patient presented with complaints of difficulty with speech and may have had left-sided weakness. Acute stroke required exclusion. Acute stroke could be ruled out via a CT and CT angiography, and if negative via MRI, in the emergency department or under observation. Once acute stroke was ruled out, the patient could be discharged with plans for further workup as an outpatient. Once acute stroke was ruled out, there would be no expectation of progressive neurological deficits. The patient therefore did not require frequent neurological checks neurological monitoring. There is no need for any other form of medical monitoring, including cardiac, hemodynamic, electroencephalographic, or pulmonary. There was no evidence of any findings requiring an acute level of care and the acute inpatient hospitalization was not medically necessary. 

"Acute ischemic stroke is a major public health priority and will become increasingly relevant to neurologists of the future. The cornerstone of effective stroke care continues to be timely reperfusion treatment. All patients should be admitted directly to an acute stroke unit for close monitoring for early neurological deterioration and prevention of secondary complications. Prompt investigation of the mechanism of stroke allows patients to start appropriate secondary preventative treatment. Future objectives include improving accessibility to endovascular thrombectomy, using advanced imaging to extend therapeutic windows and developing neuroprotective agents to prevent secondary neuronal damage" (2). 

"Appropriate treatment of ischemic stroke is essential in the reduction of mortality and morbidity. Management of stroke involves a multidisciplinary approach that starts and extends beyond hospital admission" (1). 

"The treatment of acute ischemic stroke continues to advance. The mainstay of treatment remains intravenous thrombolysis with alteplase. Recent studies demonstrated that later treatment with alteplase is beneficial in patients selected with advanced imaging techniques" (3). 
                                               
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.