Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right side weakness
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is modified
 
This case involves an adult diagnosed with hypertension who was seen in the emergency room with transient distal right arm and distal right leg mild weakness and numbness.  On examination, weakness graded 4/5 was noted to the right arm and leg.  A computed tomography (CT) of the head showed no acute parenchymal process with laboratory findings relatively unremarkable.  The assessment indicated that the patient was suspected of having a subcortical stroke based on presentation with small vessel disease as a likely mechanism.  The patient was subsequently admitted for further work-up with initial administration of aspirin and Crestor.  Upon further assessment, the patient was not found to have suffered a stroke but remained on inpatient status until discharge.  

The patient's initial examination revealed right arm and right leg weakness graded 4/5 with approximately 20% reduced sensation in the right arm and leg compared to the left.  Her National Institutes of Health (NIH) stroke scale was 2, and per neurology, was likely due to subcortical infarct.  The argument was that computed tomography angiogram (CTA) along with head magnetic resonance angiogram (MRA) demonstrated a beaded appearance of the distal cervical internal carotid artery (ICA), tortuous distal left ICA, which appeared narrowed and bilateral distal cervical vertebral arteries suspicious for fibromuscular dysplasia.  The patient's services consisted of intravenous fluids, subcutaneous Lovenox, aspirin, brain magnetic resonance imaging (MRI), transthoracic echocardiogram (TTE), and consultations with physical therapy, Occupational Therapy, and speech/language pathology.

According to the Milliman Care Guidelines (MCG), clinical indications for admission to inpatient care for individuals thought to be suffering from a transient ischemic attack (TIA) include 1 more of the following to include hemodynamic instability, recurrence of focal neurologic signs, findings on brain imaging that require inpatient care to include a mass, altered mental status, cardiac arrhythmias of immediate concern, clinically significant cardiac or vascular disorders that require inpatient care, severe hypertension, prolonged cardiac telemetry monitoring needs, suspected vasculitis, pregnancy, or parenteral anticoagulation requirements to include embolic etiology of TIA, or a need for inpatient anticoagulation therapy.  The information provided for the review noted that the patient had an NIH Stroke Scale score of 2 indicating a minor stroke.  CT/MRA revealed tortuous and irregular bilateral right greater than left ICA.  These findings indicated that further work-up was needed and inpatient care was reasonable initially as per MCG for TIA guidelines. As such, the full hospital admission was not supported.  Inpatient admission for one day was medically necessary. 

Based on the above, the insurer's denial must be modified. The health care plan acted reasonably in part.

The medical necessity for hospital admission for one day is substantiated. Continued stay is not substantiated.