Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lower Extremity Pain, Weakness
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history significant for posttraumatic stress disorder, major depressive disorder (MDD), bipolar disorder, seizures, gastroesophageal reflux disease (GERD), gastritis, chronic pain, fibromyalgia, endometriosis, spinal stenosis, and seizure who presented to the emergency department with complaints of right lower extremity weakness.

At the time of admission, the patient reported chronic symptoms such as abdominal pain, nausea, vomiting, bilateral lower extremity neuropathic pain. Her other symptoms included worsening memory, urinary incontinence, pain in the eyes with radiation to the temporal areas and forehead. Reportedly, in the last two days before the presentation, the patient noticed a band-like pain around her groin area as well as weakness in the right lower extremity that caused her to fall in her apartment.

While in the emergency department, the patient appeared to be afebrile and hemodynamically stable. It was mentioned that her oxygen saturation was within normal limits. The laboratory evaluation was unremarkable.

When the patient was seen by the admitting physician, she was afebrile. The blood pressure was 109/77, pulse rate 68 beats per minute (bpm), respiratory rate 20 breaths/minute, and the oxygen saturation was normal. The patient was lying in bed in no acute distress. The head, eyes, ears, nose, throat (HEENT) exam was within normal limits.

The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. The lungs were clear to auscultation. The abdomen was soft and non-tender in all four quadrants.

There was no edema in the extremities but the patient was unable to flex or extend her hip or knee. She was unable to dorsiflex or plantarflex her right foot. She was unable to wiggle her toes. The rest of the exam was unremarkable.

Laboratory evaluation revealed that the white blood cell count was 5.7, hemoglobin 16.4, hematocrit 46.1, and platelets 339. The sodium was 141, potassium 3.8, chloride 104, bicarbonate 25, blood urea nitrogen (BUN) 9, creatinine 0.83, and glucose 70. Liver function tests were unremarkable. The international normalized ratio (INR) was normal. The patient tested negative for influenza and coronavirus disease 2019 (COVID-19).

The patient was admitted to the hospital and was seen by the neurologist. A magnetic resonance imaging (MRI) scan of the brain, MRI of the cervical and thoracic spine, lumbar MRI, and electroencephalogram (EEG) were recommended. These studies were performed and demonstrated no obvious structural abnormalities that could explain her symptoms. The patient was evaluated by physical and occupational therapy and was recommended acute rehabilitation at the time of discharge, which she refused and opted to go home.

According to the discharge summary on the day of discharge, the patient was seen ambulating by herself with a walker and was able to shower without assistance. Since she was medically stable, she was discharged home. At issue is the medical necessity of an inpatient stay.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.

The thorough evaluation performed in the hospital did not demonstrate that the patient had any organic reasons for her symptoms. The symptoms were not associated with hemodynamic instability, altered mental status, cardiac arrhythmias of immediate concern, or severely elevated blood pressure. The imaging studies did not demonstrate a demyelinating disorder, acute stroke, or any other acute abnormalities that would require any intervention in the inpatient settings. The patient's laboratory results were unremarkable. She had no evidence of psychiatric emergencies.

Overall, this patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.

There was not a compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care. The new onset of neurologic symptoms should always be taken seriously, however, in this clinical case, the patient underwent a thorough evaluation, which included multiple imaging studies, which did not reveal significant abnormalities that could explain the symptoms. During the hospital stay, the patient's symptoms gradually improved to the point that she was able to be discharged home.

Neither the severity of the patient's condition nor the complexity of the services provided rose to the level of acute inpatient care.