Diagnosis: Stroke

Treatment: Inpatient admission

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

This patient is a male who has a medical history to include hypertension as well as hyperlipidemia and immune disorder. The patient presented to the Emergency Department (ED) complaining of a severe headache with numbness and tingling to the left side of his face and arm and left-sided facial droop. There is a lack of official hospital notes submitted however an appeal letter indicated the patient on examination had a blood pressure of 143/103 with a pulse of 79 and respiration rate of 19. The patient did undergo laboratory studies revealing a BUN of 20 with creatinine 1.33. The patient was noted to be positive for cocaine and an EKG showed a sinus rhythm with 1-degree atrioventricular (AV) block. Labs and imaging were also recommended. He was admitted to telemetry out of concern for an evolving right MCA lacunar infarct. He was placed on aspirin and statins and blood pressure were monitored. The patient continued with monitoring and was noted to have a diagnosis of complicated migraine with cocaine abuse. He was discharged the following day with instruction to follow-up. This patient with a clinical history of hypertension presented with left-sided facial numbness, left-sided upper extremity numbness with left-sided facial droop with elevated blood pressure of 143/103 with positive toxicology testing for cocaine with EKG showing 1-degree AV block. He was admitted to the hospital with concern for stroke.

According to the referenced literature the patient may be admitted to inpatient services when there is evidence of vasculitis, severe CNS infection, cerebral aneurysm, new onset severe neurologic findings, multiple sclerosis or other acute demyelinating disease requiring inpatient care or complications of neurologic devices. Within the submitted documentation the above is not present. The patient presented with headache and elevated blood pressure. Imaging study was negative for stroke. He could have been seen in the ED, observed in the ED and/or on an observation basis while stroke was excluded along with expeditious outpatient follow up with neurology; admission was not medically necessary.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The carrier's denial of coverage for the inpatient admission is upheld. The medical necessity is not substantiated.