Appeal type: Medical necessity
Decision: Upheld

This is a patient with a past medical history significant for hypertension and diabetes mellitus who was admitted to the hospital because of abnormal computed tomography (CT) scan of the head results. Reportedly, the patient went to the emergency department with complaints of pain and paresthesias in her right upper extremity. Approximately one week before the day of admission, the patient went to see her primary care physician due to upper respiratory infection symptoms. At the time of the visit, the patient was found to have severely elevated blood pressure that reportedly was 200/140.
At that time, the patient was prescribed antihypertensive medications. Later on, the patient noticed two episodes of weakness in the right upper extremity that precluded her from work. Concomitantly, the patient noticed blurry vision. According to the history and physical (H&P) note, the weakness progressively increased on the day of admission and involved the right shoulder and right side of the neck. It was also indicated in the history and physical (H&P) note that the patient's daughter noticed that her mother was not behaving as her usual self.
While in the emergency department, the patient was seen by a neurologist. Based on the imaging studies, it was suspected that the patient could have hypertensive angiopathy with multiple hypodensity images that could represent small lacunal infarcts versus metastases. It was reported that the initial laboratory evaluation was unremarkable.
When seen by the admitting physician the patient was afebrile, her blood pressure was 169/81, heart rate 66, respiratory rate 18, and oxygen saturation 99% on room air.
When seen by the admitting physician, the patient was sleepy after she received sedation for a magnetic resonance imaging (MRI) study. She was oriented and cooperative. A head, eyes, ears, neck, throat (HEENT) exam was unremarkable. A neck exam showed no jugular vein distention (JVD), adenopathy. The cardiovascular exam was unremarkable. The respiratory exam was within normal limits. The abdominal exam was benign. The neurologic exam revealed normal tone and moderate capacity in the upper and lower extremities. Proprioception was decreased in both lower extremities, pain and vibration were intact. The patient had some hyporeflexia but the Babinski reflex was negative.
Initial laboratory evaluation revealed that the white blood cell count was 11.0, hemoglobin 14.1, hematocrit 41.4, and platelets 247. Sodium was 139, potassium 4.1, chloride 102, bicarbonate 29, blood urea nitrogen (BUN) 16, and creatinine 0.69.
An MRI of the brain was performed and demonstrated no evidence of an acute infarct, intracranial mass, or mass effect. The patient had numerous old small lacunar hemorrhagic infarcts versus cavernous malformations in the cerebellum, thalamus, basal ganglia, and some other areas. The patient also underwent a CT angiogram of the head and neck, which was an essentially unremarkable study.
The patient was admitted to the hospital with a diagnosis of right arm paresthesia, radiculopathy versus CVA versus metastasis versus vitamin A deficiency.
During the hospital stay the patient was seen by a neurosurgeon who suggested a CTA of the head, to perform neuro checks, and to perform MRI of the brain. During the hospital stay the patient was also seen by a neurologist.
The neurologist suggested that the patient could have hypertensive angiography versus amyloid angiopathy with recent left parietal hemorrhage.
Within a short period of time, the patient's clinical condition significantly improved. Her blood pressure normalized. The patient was evaluated by physical and occupational therapy and was cleared for discharge home. At issue is the medical necessity of an inpatient stay.
The health plan's determination is upheld. The patient's condition improved very quickly, she had no alarming signs on the physical exam or in the laboratory studies. The diagnostic studies did not show any acute findings. 
This patient presented to the hospital with complaints of pain and paresthesias in the right upper extremity as well as blurry vision. It was noted that her blood pressure was severely elevated at the time of the initial evaluation. At the same time, when seen by the admitting physician the blood pressure was much better controlled.
Most importantly, by the time of the initial evaluation by admitting physician the patient had no clinically significant abnormalities on the neurological exam. It was clearly documented that the patient had a normal tone and muscle strength in the upper and lower extremities. The decreased proprioception, hyporeflexia were rather nonspecific signs.
The results of the laboratory studies were unremarkable. The diagnostic tests, especially MRI, demonstrated abnormalities that were rather chronic and did not represent an acute process that would require admission to the hospital at the acute inpatient level of care.
It was clearly indicated in the MRI report that there was no evidence of an acute infarct, no intracranial mass, or mass effect. According to the radiologist, the patient had numerous old lacunar hemorrhagic infarcts.
Taking into consideration all of this information, there was no overwhelming evidence that the patient had an acute medical condition necessitating admission at the acute inpatient level of care.
The patient's symptoms resolved quickly, including her neurologic symptoms. Her blood pressure improved very quickly. The patient was able to ambulate and was able to consume meals without difficulties. Care could have been provided at a lower level than inpatient.