Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Headache.
Treatment: Inpatient Stay.
The insurer denied the Inpatient Stay.
The determination is upheld.

The patient has a past medical history of anemia, migraine headaches, and possible syncope versus seizure who presented to the emergency department with concerns for left-sided weakness, a headache, and nausea.
On presentation, she was afebrile with a blood pressure of 138/84, heart rate 80, respiratory rate 18, and an oxygen saturation of 92% on room air. The exam otherwise noted her to be alert and oriented with left hand and lower extremity strength noted to be 4/5, and with her neck noted to be supple. Labs resulted with a white blood cell count (WBC) of 5.4, hemoglobin (HGB) 10, platelets 325, sodium 138, potassium 4.3, blood urea nitrogen (BUN) 13, and creatinine 0.69. A urinalysis was negative. A chest x-ray and computed tomography (CT) scan of the head showed no acute process. An electrocardiogram showed no acute ischemia or arrhythmia. The patient was brought into the hospital with concerns for a headache and 4/5 extremity weakness on the left with a concern for a transient ischemic attack versus complicated migraine, and with plans for neurology checks every 4 hours, neurology consultation, magnetic resonance imaging (MRI), and consideration of Imitrex for headaches.
Neurology saw the patient with the impression that she had likely status migrainosus and with plans for an MRI, and trial of Imitrex.
The patient was noted to be hemodynamically stable. She had ongoing weakness of her left upper and lower extremities at 3/5 with dizziness and a headache. The plan was for MRI, orthostatics, and physical therapy. The MRI was noted to be negative. The neurology assessment was that the patient had a complex migraine with the recommendation that she could follow up in the outpatient setting for further management.
The patient had ongoing weakness of her upper and lower left extremity. She was discharged with a diagnosis of complex migraine and plans for Imitrex and outpatient physical therapy.
At issue is the medical necessity of an inpatient stay.

Inpatient stay was medically necessary for this patient presenting with a significant acute neurologic deficit of 3/5 strength in the left upper and lower extremities requiring frequent neurologic checks, work-up for cerebrovascular accident, and at risk for worsening neurologic deficits in addition to cerebrovascular accident as a complication of complicated migraine.
This is a patient who presented with significant and persistent weakness of her left upper and lower extremity noted to be 3/5. There was concern was for a transient ischemic attack versus complex migraine, and she required close neurologic monitoring with frequent neurologic checks and assessment of change or progression of neurologic symptoms in addition to MRI and need to rule out frank cerebrovascular accident given her severe persistent weakness. She was at risk of worsening hemiplegia and permanent neurologic deficits which can occur with either cerebrovascular accident or hemiplegic migraine, and was only able to be safely discharged after she was ruled out for cerebrovascular accident and it was clear her left-sided weakness was not worsening. Inpatient level of care was medical necessary for this patient presenting with significant left sided weakness of 3/5 with associated headache with need for frequent neurologic checks, rule out for cerebrovascular accident, treatment of her migraine, and with inability to safely discharge prior to assurance that her weakness was not worsening (though it was still present at discharge).