Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Possible Cerebral Vascular Accident (CVA)
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

This case involves an adult male who presented to the emergency department complaining of stroke-like symptoms.  He had a witnessed syncopal episode and was helped to the ground.  He sustained no head injury, but did have questionable posturing.  
Emergency medical services noted right facial droop and repetitive speech.  The patient had a history of hypertension and was taking amlodipine.  He was a poor historian and was in and out of confusion.  He complained of headache and numbness to the right side of the face.  His National Institutes of Health (NIH) stroke scale score totaled 18, indicating moderately severe stroke.  A primary computed tomography angiography (CTA) was negative and perfusion computed tomography (CT) was negative.  The report stated the patient was critically ill with a high probability of imminent or life-threatening deterioration.  The patient's vital signs noted elevated blood pressure at 136/100.  The patient reported 10/10 pain and had a Glasgow coma score of 12 given the noted confusion.  Associated symptoms included aphasia, loss of vision, facial droop, weakness, slurred speech, and the inability to assess balance.  The event notes stated the patient was confused, lying on the floor, and was very agitated and noncompliant with instructions.  He did not know where he was or how he got there.  Ativan 0.5 milligrams (mg) intramuscular to be administered every 6 hours was ordered.  While imaging of the head/brain was negative, a chest x-ray showed mildly increased interstitial markings without focal airspace opacity, pleural effusion, or pneumothorax.  The patient was admitted to medicine telemetry for altered mental status, cerebrovascular accident, hypertension, and acute stroke.  He continued to receive treatment until discharge the following day.  His Glasgow coma score improved to 15.  Additionally, his NIH stroke scale total was 0.  The patient was able to answer questions with normal responses and examination showed normal strength in the upper and lower extremities, normal pupil size, shape, reaction, and accommodation.  Reflexes were 2+ with no discoloration, numbness, or tingling in the extremities.  The patient was subsequently discharged the following day in stable condition.  This review pertains to the denial of coverage for an inpatient hospital admission.

According to the Milliman Care Guidelines (MCG), clinical indications for admission to inpatient care regarding syncope include those who are hemodynamically unstable, have severe or persistent altered mental status, when they have cardiac disease or findings that indicate a necessity for immediate intervention, when the patient has pacemaker or automatic implantable cardioverter-defibrillator (AICD) malfunction, inheritable cardiovascular conditions predisposing to arrhythmias diagnosed or suspected, they have severe persistent dehydration, or syncope causing injury requiring hospitalization.  While the evidence noted the patient had a syncopal episode and altered mental status, he responded favorably to treatment and had relative resolution of symptoms.  There were no significant abnormalities noted on diagnostic imaging with normal findings on CT and CTA.  Given the provided information, it was determined that inpatient hospitalization was not needed in this case and that the patient's care could have been safely and effectively rendered on an observational basis.  

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. 

The medical necessity for an inpatient hospital admission is not substantiated.