Appeal type: Medical necessity
Decision: Overturned

Diagnosis: unsteady gait, nausea, left-sided weakness

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned
 

This case involves an adult female, who presented to the emergency department (ED)
from her doctors' office, with complaints of unsteady gait, nausea, left-sided weakness,
intermittent right-hand tingling, and dizziness of 1-week duration. The patient endorsed a medical history significant for hypertension (HTN), asthma, colitis, urolithiasis, gastric bypass, depression, obesity (Body Mass Index (BMI) 36.4), and is a current every-day smoker. Upon arrival to the ED, the patient was hypertensive with blood pressure 195/113 with pulse of 101. On examination, the patient reported that the dizziness has prevented her from ambulating.  She reported left arm and left leg weakness. There was horizontal nystagmus on the left with dizziness worsened with left side head movement. Physician noted National Institute of Health Stroke Scale score of 2 with left motor leg drift of 1 (leg falls by the end of the 5 second period but does not hit bed) and left motor of 1 (holds 90 or 45 degrees but drifts down before full 10 seconds, does not hit bed).  The provider felt that the patient had medical necessity beyond the capabilities of an Emergency Department for possible cerebrovascular accident which required neuromonitoring and further evaluation.  

Per the Milliman Care Guidelines (MCG) 27th Edition- Inpatient Level of Care; neurology inpatient admission indication includes inpatient monitoring/treatment required; Neurology Consultation; serial neurological assessments. The clinical documentation support this guideline criteria for admission. 

Per the MCG Guidelines, admission to inpatient level of care is indicated when there are neurological findings of weakness that is progressive or severe, vertigo that is severe (inpatient care needed due to functional disability) or when there are other severe neurologic findings not treatable at an alternative level of care.  Admission is indicated for those with acute ischemic stroke with clinical need for inpatient care or monitoring as indicated by severe hypertension (systolic blood pressure greater than 180 or diastolic blood pressure greater than 120).  It is recommended for acute ischemic stroke with neurological findings that would warrant inpatient care such as gait impairment or significant arm or leg weakness.  

Based on the clinical documentation the patient was deemed unstable for discharge in setting of presenting symptomatology concerning for acute neurologic event, possible acute cerebrovascular accident (CVA). The patient had symptoms suspicious for acute stroke with initial blood pressure documented as severe (195/113) with systolic blood pressure greater than 180, tachycardia, increased risk factors of current tobacco use, reported gait impairment, and unilateral leg and arm weakness noted on exam. The symptoms of possible stroke combined with severe hypertension upon presentation meets MCG criteria for admission.  

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an inpatient admission is substantiated.