Diagnosis: Lower extremity weakness.
Treatment: Inpatient admission.

The insurer is denied coverage for inpatient admission.

The denial is upheld.

This female patient has a history of right sided breast cancer.

The patient presented to the emergency department (ED) with a 2-3 day history of lower extremity weakness. Neurology was consulted. The patient was treated with intravenous (IV) fluids and felt much better the following day and could ambulate without assistance. The patient was then discharged to home with outpatient follow up arranged. Care provided, including diagnostic testing, specialty consultation and medical management which could have been performed in the ED and at an observation level of care. Therefore, the inpatient admission was not medically necessary.

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 inpatient admission is upheld. The medical necessity is not substantiated.