Diagnosis: Cardiovascular Accident

Treatment: Hospital Admission

The insurer denied coverage for hospital admission

The denial is upheld

This case involves a female who presented to the Emergency Department with complaints of left-sided weakness. The documentation indicated while in the emergency department she was stable. She was recommended to undergo a computed tomography scan as well as multiple laboratory studies. Computed tomography scan of the head did not show any acute abnormality. There was no stenosis or occlusion on Computed Tomography Angiogram. The patient was noted to be alert and oriented. She was in moderate distress and had anxiety related to her condition. The patient reported continued left-sided numbness to the face as well as lower extremity. The submitted documentation indicated it was recommended she undergo a consultation with neurology and follow-up with a brain magnetic resonance imaging. The patient was also recommended to be admitted for further evaluation. The patient did undergo an evaluation by Neurology where it was determined that ischemia was a less likely cause. She was noted to have a possible psychiatric component. She was evaluated by psychiatry and was noted to have ongoing depression. The patient was noted to have complaints of stress. She did indicate she was motivated to continue care and participate in additional services. The patient was treated with multiple medications while hospitalized which included benzodiazepines. The patient was also recommended to undergo a physical/occupational therapy evaluation. She continued with treatment and had no further significant adverse events. She did undergo a physical therapy consultation. The recommendation was made for restorative physical therapy services. The documentation indicated the patient was alert and oriented however in moderate distress and continued multiple questions about her anxiety. The documentation detailed she did continue with treatment and given there was a period of stability without further decline, the patient was discharged.

Admission for possible cardiovascular accident was not clinically appropriate as the needed evaluation due to her presenting symptoms could have been done during a period of observation. Given no significant findings and stability the inpatient stay was not appropriate. She could have followed up with a lower level of care as she was stable.

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

The insurer's denial of coverage is upheld. Medical Necessity is not substantiated.