Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cerebrovascular accident (CVA) versus seizure disorder

Treatment: Inpatient hospital stay

The insurer denied coverage for the inpatient hospital stay.

The denial is upheld. 

This is a female patient with a past medical history of migraines. The patient presented to the Emergency Department (ED) after being seen at an urgent care facility. The patient reported that she woke up that morning with a headache and took Motrin and Tylenol.  Shortly after taking medication, the patient had a syncopal episode. The patient indicated that her husband was home and noticed the event. The patient indicated that she was having a hard time getting words out for which she went to an urgent care facility. From there, the patient was transferred to this hospital via the emergency medical services (EMS). 

The patient reported that in route to the hospital, her symptoms began to resolve.  While in the ED, she reported having no deficits or difficulty in speaking. She did not complain of any headache and she did not have any significant abnormalities on physical examination. The patient's computed tomography (CT) scan of the head did not show any acute findings. It was recommended that the patient undergo a neurology consultation. It was also recommended that the patient be admitted for cerebrovascular accident (CVA) versus seizure disorder. The patient's symptoms reportedly had significantly improved by the time she presented to the ED. The patient did not have any significant findings and it was recommended that the patient undergo a magnetic resonance imaging (MRI) of the brain. The physician detailed it was most likely an atypical migraine. The recommendation was also made to treat the patient with aspirin and a statin until the MRI is performed. Documentation indicated that the patient left against medical advice (AMA) the same day of admission. 

Regarding the requested inpatient stay, literature indicates that a patient may be admitted to inpatient services when there is evidence of hemodynamic instability, altered mental status that is severe or persistent, evidence of cardiac ischemia, sustained or systemic ventricular tachycardia, symptomatic conduction system disease, dehydration that is severe or persistent, supraventricular tachycardia or bradycardia or sinus pauses.  In this case, the patient was seen in the urgent care after complaining of a syncopal episode. The patient was then transferred to the ED. However, upon arriving to the ED, the patient's deficits had returned to baseline. There was no evidence of any type of significant hemodynamic or neurological instabilities. Documentation does not detail any type of cardiac ischemia or disease or finding indicating necessity of immediate intervention. Therefore, the need for inpatient services was not necessary. While observation may be appropriate for this patient, the inpatient hospital stay was not medically necessary.

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

The carrier's denial of coverage for the inpatient hospital stay should be upheld. The medical necessity is not substantiated.