Central Nervous System/Neuromuscular Disorder - Other
Inpatient Hospital

The patient is a female with a history of hypertension, hypothyroidism, fatty liver, and depression. Very early in the morning she presented to the emergency room several hours after experiencing lightheadedness and near syncope when she got out of bed. In addition, she noted a perioral tingling, which resolved shortly after arriving at the hospital. The vital signs and physical exam, including the neurologic exam, were normal. Labs were non-contributory. The computed tomography (CT) scan was negative for an infarct but showed a "Questionable 4 millimeter (mm) left parietal vague hyperdensity versus artifact". The electrocardiogram (EKG) was negative as well. The neurology consultant evaluated the patient and concluded that the patient did not have a transient ischemic attack (TIA), her symptoms were mostly likely due to a transient blood pressure (bp) pressure drop (perhaps vasovagal), and the CT scan finding was an artifact. No further tests or treatment were recommended. Regardless, the patient was admitted for further evaluation and treatment.
Upon admission to a monitored bed, the patient was treated with an aspirin, a statin, and her usual levothyroxine. The hospital course was clinically uneventful, and she was discharged later that day.
The subject under review is the medical necessity of the inpatient stay.

The health plan's determination is upheld.

Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints. There was no credible evidence that the patient suffered a TIA. Based on the standard of care and peer reviewed literature, the inpatient level of care was not medically necessary, and the patient could have easily and safely been managed at a lower level of care status.