Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder.
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

The patient is a female with a past medical history significant for hypertension, vascular dementia, and cerebrovascular accident (CVA) who was brought to the hospital by her daughter because of a transient episode of confusion associated with mumbling and right-sided weakness.

Reportedly, at the baseline, the patient was able to ambulate without assistance, but because of dementia she had minimal verbal output and was dependent with all her activities of daily living. On the day of admission, the patient woke up in her usual state of health but as the day progressed, the patient's daughter found her on the floor. At that time, the patient was confused and mumbling. This was not typical for her at the baseline. The patient's daughter also noted that the patient had difficulties with moving her right upper and lower extremities.

On the neurologic exam, the patient was awake, alert, and oriented to self, but not to place, person, or situation. The patient was able to follow one-step commands intermittently. The rest of the physical exam was unremarkable. Computed tomography (CT) scan of the head showed no acute intracranial findings.

At the time of admission, it was suspected that the patient could have transient ischemic attack (TIA). Imaging studies including magnetic resonance imaging (MRI) of the brain, magnetic resonance angiography (MRA) of the head and neck, as well as an echocardiogram, were ordered. MRI of the brain was performed and demonstrated no evidence of acute ischemic stroke. There was no evidence of significant white matter disease or cerebral microbleeds. There was atrophy in the frontal and temporal regions, which could be suggestive of a neurodegenerative disorder other than vascular dementia. Electroencephalogram (EEG) was negative for seizures. Since the patient remained in stable clinical condition, she was discharged from the hospital with a recommendation to continue workup for neurodegenerative disorder. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld.

The inpatient stay was not medically necessary for this patient. 

According to the nationally accepted standards of care, the acute inpatient level of care is generally indicated in cases of transient ischemic attack associated with hemodynamic instability, persistent or recurrent focal neurologic signs, in cases when TIA is suspected, but an acute stroke is diagnosed.

The admission at the acute inpatient level of care is also required for patients with TIA associated with altered mental status, cardiac arrhythmias of immediate concern, a clinically significant cardiac disorder such as severe valvular disease, atrial myxoma, cardiomyopathy, cases of severe hypertension that could not be controlled by the emergency department or at the observation level of care, certain cases when patients require inpatient procedure or surgery such as endarterectomy, also in cases when parenteral anticoagulation or administration of antiplatelet agents is required.

The review of the medical records clearly demonstrated that in this clinical case the patient had no circumstances listed above. The workup and clinical monitoring could have been performed at a lower level of care status.