Diagnosis: Bell's Palsy.
Treatment: Inpatient admission.

The insurer is denied coverage for inpatient admission.

The denial is upheld.

This female patient has a history of hypertension, fibromyalgia, Lyme disease, possible recurrent Bell's Palsy, recurrent bronchitis, and anxiety/depression.

Milliman Care Guidelines (MCG) recommends admission for acute ischemic stroke with neurologic findings when there is National Institutes of Health Stroke Scale (NIHSS) score greater than 2, evidence of hemorrhagic transformation, altered mental status, findings that warrant inpatient physical or occupational therapy treatment or evaluation, dysphagia that warrants evaluation (eg, aspiration risk suspected), significant arm or leg weakness (eg, limiting movement against gravity), aphasia, gait impairment, or finding on brain imaging that requires inpatient care (eg, mass, edema, large acute infarction). The patient was noted to have a NIHSS score of 4; however, 2 points were for facial palsy. This resolved and the patient had a history of Bell's palsy. While the patient did have arm and leg weakness this would not be significant (limiting movement against gravity) as motor strength was noted as 4+/5 right upper extremity weakness and 4/5 right lower extremity. The patient had a history of hypertension and blood pressure was under control prior to admission. Imaging of the brain was normal. The patient could have been monitored, treated, and underwent testing in a lower level of care to include observation. As such, the denial of coverage for the inpatient admission at Richmond University Medical Center is upheld.

The health plan did act reasonably with sound medical judgment, and 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.