Diagnosis: Cerebrovascular Accident.

Treatment: Inpatient admission.

The insurer denied the inpatient admission.

The denial was upheld.

This is a female patient with a medical history of cerebrovascular accident without residual deficits and diabetes mellitus. The patient was brought to the Emergency Room (ER) by the ambulance with complaints of bilateral foot weakness and a cough. Her presenting vital signs were: blood pressure was 156/93, heart rate was 71 bpm, temperature was 98.6 °F, and respirations were 16. The patient was alert, awake, and responding to voice. The patient reported that the weakness began a couple of days prior to presentation. The patient was able to stand with an unsteady gait; she was dragging her left foot. The patient noted that the last time she had similar symptoms she had a stroke, which had resolved. The patient's physical examination revealed cranial nerves II through XII were grossly intact with no focal neurologic deficits. A computed tomography (CT) scan of the head was performed with negative results. A lumbar puncture was performed that revealed normal results. The patient was admitted to the hospital to rule out a cerebrovascular accident. It was reported in the patient's history and physical note that the problem was Guillain-Barre syndrome (GBS) based on recent upper respiratory infection in 2 days of progressive bilateral lower extremity weakness, and hyporeflexia. A magnetic resonance imaging (MRI) of the brain was performed that revealed no acute infarction. The patient was discharge to a rehabilitation facility for reconditioning.

Based on the review of the medical record, the patient presented to the Emergency Department (ED) with lower extremity weakness with a prior history of upper respiratory infection (URI), raising the suspicion for Guillain-Barre Syndrome (GBS). The patient's lumbar puncture was negative from the standpoint of GBS. The patient's magnetic resonance imaging (MRI) of the brain and computed tomography (CT) of the head CT were both negative from the standpoint of acute stroke. The patient's diagnostic tests, such as the lumbar puncture, CT imaging study of the brain, MRI of the brain, and neurology consultation all could have been performed in the ED setting or at an observation basis. Clinical guidelines do not support inpatient admission for this patient. Thus, inpatient admission was not medically necessary.

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

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