Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left oculomotor nerve palsy 
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The health plan's determination is upheld.

The patient is a male who initially presented to the emergency department with complaints of (c/o) a headache, left eye pain, and ptosis of a two week duration. His pertinent history included outpatient evaluations by his primary care physician and ophthalmologist. Additional history included migraine headaches. The initial vital signs revealed a temperature of 98, heart rate (HR) 105, blood pressure (BP) 134/87, respiratory rate (RR) 20 and his peripheral capillary oxygen saturation (SpO2) was 98 percent (%) on room air. The initial examination documented a left medial gaze palsy with ptosis and diplopia. The initial laboratory testing revealed a white blood cell count (WBC) 14.0, hematocrit 46, blood urea nitrogen (BUN) 12.1, creatinine 1.04 and his glucose was 137.
The electrocardiogram (EKG) was unremarkable. The computed tomography (CT) of the head was unremarkable. The computed tomography angiography (CTA) of the head was unremarkable. The patient was placed in the hospital thereafter with an impression of left eye oculomotor palsy. The treatment plan included additional diagnostic testing and consultations. No additional issues were noted. The magnetic resonance imaging (MRI) of the brain was unremarkable. Neurology was consulted who had an impression of a left 3rd cranial nerve palsy. Recommendations were to obtain a magnetic resonance angiography (MRA) of the brain. The MRA of the brain was unremarkable. There was no significant change to the treatment. There were no new issues. Additional diagnostic laboratory tests ordered. There was no change in treatment. The additional serology was negative. The patient was discharged with plans for outpatient follow-up.

Based on the clinical documentation provided, evidence based literature and standards of care, an acute inpatient level of care was not indicated as medically necessary for the entire admission. Evaluation and management could have been performed at an alternate level of care.
 
The patient had a history of left oculomotor nerve palsy that improved with conservative management 8 years prior who presented with left oculomotor nerve palsy. A comprehensive evaluation including extensive serology tests, CT, CTA, MRI, and MRA head imaging were performed and essentially unremarkable. Treatment was essentially supportive care. No intervention was performed or deemed necessary. No other issues or complications were documented and the patient was discharged with plans to follow-up in the outpatient setting.
Clinical indications for admission to inpatient care were not met. The patient did not have severe eye inflammation (e.g., retinal arteritis) that requires treatment beyond scope of observation, severe eye infection that requires treatment beyond scope of observation, ocular injury or trauma requiring treatment beyond scope of observation, optic neuritis requiring treatment beyond scope of observation care, central retinal arterial occlusion that requires evaluation or treatment beyond scope of observation care, or ocular or visual findings (e.g., diplopia, abnormal ocular examination) with suspected etiology that requires evaluation or treatment beyond scope of observation.[2]
 
The health plan's determination of medical necessity is upheld in whole.