Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems/Stroke/CVA
Treatment: Inpatient Hospital
The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is upheld.

The patient is a female with a past medical history that includes a stroke (with no residual deficits) and hypertension (not on medication). The patient presented to the emergency department (ED). The patient presented with a complaint of "generalized weakness" for the preceding 3 weeks. The patient also reported a prior episode, about 1 hour in duration of weakness in the right lower and upper extremities associated with numbness. The patient presented to the ED on the advice of her cardiologist for complaints of chest pain, shortness of breath (SOB) and fatigue. The patient did endorse a headache.

In the ED, a computed tomography (CT) of the head was negative for an acute process. A computed tomography angiography (CTA) of the head showed a hypoplastic left posterior cerebral artery (PCA P1) segment. There was a diminutive left posterior cerebral artery, limiting the evaluation. There was questionable moderate to marked narrowing of the left PCA. A CTA of the neck showed no findings of concern.

In the ED, her neurological examination was non-focal. She had a National Institute of Health Stroke Scale (NIHSS) of 0. A decision was made to take the patient to the floor for further evaluation.

The patient was seen by cardiology and neurology during the stay. A magnetic resonance imaging (MRI) of the brain was done and showed no acute findings.

During the hospitalization, the patient underwent a transthoracic echocardiogram (TTE) which showed no significant findings. The patient also underwent a transesophageal echocardiogram (TEE) which was unremarkable. The patient underwent a CT of the chest which showed some ground glass nodules for which follow-up imaging was recommended.

She remained in the hospital until her work-up was completed and she was discharged.
At issue is the medical necessity of the inpatient stay.

The health plan's determination of medical necessity should be upheld, in whole.

No, the inpatient level of care was not necessary for the patient in this case. The patient presented with complaints of chest pain and symptoms potentially suggestive of a stroke. The plan's determination was otherwise well suited based on the generally accepted standards of care/practice

The patient's initial evaluation for a myocardial infarction (MI) was negative. Her troponins were within normal levels. Her electrocardiogram (EKG) showed no acute findings or other findings of acute concern.

The patient's initial neuroimaging was also negative for any acute intracranial process. There was no evidence of any acute large vessel occlusion.

The patient did not exhibit any focal neurological findings of concern. The patient's MRI of the brain was also negative for an acute stroke.

The patient did not exhibit any deterioration in her neurological or cardiac function during the hospital stay. There was no evidence of hemodynamic instability during the course of the stay. There was no evidence of an infection. The patient did not have any other findings or conditions that would have otherwise necessitated the provision of care at/in the inpatient setting. Rather, the care provided to the patient was more consistent with that customarily provided in the observation level of care.