Diagnosis: Nausea and vomiting, left sided weakness and facial droop
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is an male with diabetes, hypertension, and previous cerebrovascular accident (with residual left-sided deficits) who was admitted to the hospital with left-sided weakness and facial droop. Computed tomography of the brain demonstrated no acute process. Labs were notable for a potassium 5.0, blood urea nitrogen (BUN) 28, creatinine 1.7, and glucose 151. On admission the patient was afebrile with a blood pressure 137/84 and pulse 101. Intravenous fluids and a heparin infusion (for atrial fibrillation) were provided. Nephrology, cardiology, and neurology were consulted. The creatinine dropped to 1.2-1.4. Magnetic resonance imaging of the brain demonstrated no acute cerebrovascular accident. An echocardiogram demonstrated a normal ejection fraction with no cardiac thrombus or valvular abnormality. Anticoagulation was transitioned to the oral route and oral metoprolol was given. Physical therapy was provided. Gastroenterology consulted for vomiting. Upper endoscopy demonstrated duodenal hives. Oncology consulted for mediastinal lymphadenopathy noted on computed tomography of the abdomen/pelvis.

No, the proposed treatment, inpatient admission, was not medically necessary.

The patient's left-sided weakness and increased facial droop were evaluated with computed tomography and magnetic resonance imaging of the brain which demonstrated no evidence of acute cerebrovascular accident. There was no evidence of bleeding on heparin infusion. The patient's atrial fibrillation was easily rate controlled and the patient did not have hemodynamic instability or need for cardioversion or antiarrhythmic therapy. The patient had only a mild degree of acute kidney injury, with prompt improvement in renal function with intravenous fluid administration. The patient did not require dialysis and did not have hyperkalemia, uremia, acidosis, or volume overload. There was no evidence of persistent vomiting, and upper endoscopy demonstrated only duodenitis. Computed tomography of the abdomen/pelvis demonstrated no acute process.

In summary, acute inpatient admission was not medically necessary.