Diagnosis: Right-sided trigeminal neuralgia versus parietal infarct versus a cerebral infection

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission. The denial was upheld.

This patient is a female who presented to the emergency department complaining of right facial numbness with a tightening sensation to the right side of her head. She also complained of shortness of breath. Upon triage her vital signs revealed a blood pressure of 129/77. Her heart rate was 82 bpm. Temperature was normal and oxygen saturation was 100% on room air. The patient also endorsed spasm with twitching to the right eye. She did indicate she arrived from outside of the United States 1 week prior. The physical examination revealed the patient was alert and oriented. She was in no apparent distress. Neurologically, she was able to follow commands and had normal strength and sensation. It was recommended the patient undergo laboratory and diagnostic studies.

The laboratory studies did not reveal any significant abnormalities. The documentation indicated the patient had a prior CT performed outside of the country stating she had a lacunar infarct. It was recommended they admit the patient for further evaluation and to undergo an MRI. The patient was seen for a neurology consultation where it was noted the patient apparently had a CT scan previously out of the country revealing a right lacunar stroke however a CT scan performed with CTA done on admission appeared unremarkable. The physician indicated the patient had concern for right-sided trigeminal neuralgia versus parietal infarct versus a cerebral infection. It was recommended they continue with an MRI of the brain as well as transthoracic echocardiogram, a fasting lipid panel and hemoglobin A1C. The patient continued with evaluation and there were no further adverse events noted. The patient did undergo the MRI which revealed an unremarkable study. The documentation detailed she denied any further significant adverse events. She remained stable throughout the entirety of the stay. She was eventually discharged with a Medrol Dosepak. The patient was also recommended to follow-up.

There was a concern for stroke with a report of a prior imaging study performed in another country which, per report, showed a lacunar stroke. However, all of her diagnostic studies from current admission including CT of the head, CTA of the head and neck, MRI of the brain were unremarkable, showing no evidence for acute stroke. These studies could all have been performed in the ED along with neurology consultation with outpatient follow up an expeditious follow up with neurology. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

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