Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bell's palsy. 
Treatment: Inpatient hospital admission. 
The insurer denied coverage for inpatient hospital admission. 
The denial is upheld. 

This case involves an adult female who presented to the Emergency Department (ED) with right facial pain for 2 days and right upper extremity weakness. Glasgow coma score was 15. She reported right ear pain that began 2 days prior with radiation to the right face and a lack of sensation in her tongue since that morning. She reported a right-sided weakness that began later at night. The patient was speaking in full sentences with clear speech and reactive pupils. She had a past medical history significant for hypothyroidism. On examination, she had functional range of motion in all joints of the upper and lower extremities with the joint stable and nontender. Distal pulses were normal and equal bilaterally. The patient was alert and oriented with no tremors or tongue fasciculations. The right facial weakness seemed to spare the forehead. She had clear speech that was fluent with strength graded 5/5 throughout the upper and lower extremities except for 4/5 right lower extremity strength. She had normal finger-to-nose and a normal gait. Her National Institute of Health (NIH) stroke scale score was 3. National Institutes of Health Stroke Scale (NIHSS) results 1-4 indicate minor stroke. Laboratory testing was conducted with elevated glucose noted at 109. A computed tomography (CT) of the head showed no evidence of acute intracranial hemorrhage or territorial infarction. An x-ray of the chest showed no acute infiltrate seen. She had undergone serial reevaluations during her observation period in the ED. Symptoms were unchanged and she continued to exhibit very mild right upper extremity and mild to moderate right lower extremity weakness as well as right facial weakness. Her symptoms were most likely consistent with Bell's palsy, although this did not explain the arm and leg weakness. The plan was for further work-up to rule out central causes of her symptoms with plans to recheck labs, electrocardiogram (EKG), CT of the brain, and get a neurology consultation. She was not considered a tissue plasminogen activator (tPA) candidate since symptoms began greater than 24 hours prior to arrival.  

According to the Milliman Care Guidelines 27th addition, clinical indications for admission to inpatient care include those who have evidence of an acute ischemic stroke with neurologic findings that warrant inpatient care, acute ischemic stroke with clinical need for inpatient care or monitoring, thrombolysis performed or planned, or urgent inpatient procedure planned. Alternatives to admission include outpatient evaluation and treatment in an ED, rapid treatment site, urgent care center, or medical office or observational care. Observation care is indicated for 1 more of the following to include vital sign abnormality, appropriate evaluation cannot be completed in the ED timeframe of 3 to 4 hours, cardiac embolic source suspected requiring cardiac telemetry monitoring beyond ED care time frame (eg, to detect atrial fibrillation), or if the patient has NIHSS score less than or equal to 2 and monitoring of neurologic findings (eg, for worsening or recurrence of findings) beyond ED time frame (3 to 4 hours) is needed. The documentation provided for the review indicated that the patient's care could have been safely and effectively rendered on an observational basis. She was diagnosed with Bell's palsy and there were no serious abnormalities identified on laboratory testing or diagnostic imaging to support inpatient admission. It was therefore determined that the inpatient hospital admission was not medically necessary for this patient. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for Inpatient Hospital Admission is not substantiated.