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201908-120333

2019

Fidelis Care New York

Medicaid

Central Nervous System/ Neuromuscular Disorder

Inpatient Hospital

Medical necessity

Upheld

Case Summary

Diagnosis: Transient Ischemic Attack

Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld.

This is a female patient who presented to the Emergency Department (ED) with complaints of sharp right sided chest pain that radiated to her jaw and scapula region with right sided weakness. She has a history of cerebral vascular accident (CVA) without residual effects, obesity, and asthma. The patient was given nitro spray for her chest pain; relief was noted. She had an electrocardiogram and a chest x- ray which were both negative. She had a transthoracic echocardiogram (TEE) which revealed normal left ejection fraction. Neurology was called to evaluate the patient; she was ruled out for a CVA. A magnetic resonance imaging (MRI) was requested however; due to the patient's size it could not be performed. The patient regained movement in her right leg and was medically stabilized. She was discharged home the same day.


The documentation indicated that the patient did have complaints of chest pain. The patient's chest pain was improved by the use of nitro spray. The patient had no findings of a stroke on imaging. There was no indication the patient had hemodynamic instability, respiratory distress, chest pain indicative of a serious diagnosis, focal neurological signs or symptoms that persisted or recur, stroke diagnosed, altered mental status, cardiac arrhythmia immediate concern or clinically significant cardiac disorder identified that required inpatient care.

According to the American Heart Association/American College of Cardiology (AHA/ACC) guidelines, the patient's condition was appropriate for the observational level of care rather than inpatient level care.

Based on the above, the medical necessity for the inpatient admission is not substantiated. The insurer's denial is upheld.

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