Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain. 
Treatment: Inpatient admission. 
The insurer denied coverage for the inpatient admission. 
The denial is overturned. 

The patient presented to the hospital complaining of chest pain since the previous night, headache, nausea, and vomiting times 2. There was a history of asthma, congenital dilatation of pulmonary artery, and uterine fibroids status post hysterectomy complicated by right upper extremity deep venous thrombosis on Eliquis. The patient complained of persistent, generalized headache with photophobia, intermittent lightheadedness associated with 2 episodes of non-bloody, non-bilious emesis as well as substernal, pleuritic chest pain with non-exertional shortness of breath. The patient complained of decreased strength and numbness/tingling of the left upper and lower extremity that had been ongoing for 3 to 5 days. The patient utilized Tylenol without relief. The patient reported that the headache was different than prior migraines. The review of systems was positive for fatigue, shortness of breath, chest pain, nausea, vomiting, dizziness, weakness, lightheadedness, numbness, and headache. The vital signs of the patient noted blood pressure 135/97, pulse of 85, temperature of 98.5 degrees Fahrenheit, respirations of 16, and oxygen saturation of 98% on room air. The physical exam findings reported sensory deficit that was in the left upper and lower extremity and generalized weakness on the left more than the right side. The patient had difficulty lifting the lower and upper extremities that was worse on the left side than the right. There was a plan for labs to evaluate for electrolyte/metabolic abnormality, computed tomography (CT) of the head to evaluate for intracranial pathology, ventilation perfusion (VQ) scan to evaluate for pulmonary embolism, troponins to rule out acute coronary syndrome, and neuro consult due to findings on exam. An electrocardiogram noted incomplete right bundle branch block nonspecific T wave findings, and normal sinus rhythm that were consistent with prior reading. The patient reported left facial weakness the previous day. The patient had reported that they had left upper extremity weakness since having a hysterectomy. The patient also reported chronic chest pain that was worse with inspiration. Magnetic resonance imaging of the brain showed possible paraopthalmic aneurysm. Upper extremity duplex showed chronic superficial venous thrombosis in the right forehand vein. The patient was evaluated by neurology and started on a migraine cocktail. The patient had persistent migraine. The patient was treated with Tylenol, Reglan, Benadryl, and Toradol. Decadron was added for refractory symptoms. Ophthalmology was consulted for paraopthalmic aneurysm with recommendation for outpatient follow-up with neurosurgery. Repeat echcardiogram showed severe pulmonary hypertension dilatation consistent with prior.  Neuro (neurology) reevaluated the patient and recommended medical management with ambulatory referral. It was suspected the underlying social pressures from home were contributing to headache. At the time of discharge, the patient's headache had improved. There continued to be decreased left upper extremity grip strength. The left upper extremity range of motion was limited at the shoulder by neck pain. There was decreased left upper extremity sensation. 

The patient had new onset focal neurological deficit. The patient exhibited sensory deficit with a decrease in the left upper and lower extremity. The patient had motor weakness.  Thus, admission to the hospital was medically necessary. The documentation indicated that the patient had new lower extremity neurological deficit. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an inpatient admission is substantiated.