Diagnosis: Left sided numbness, weakness
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient who presented to the emergency department with concerns for left-sided numbness, weakness, and a headache. She had no significant medical history. The initial examination documented a National Institute of Health Stroke Scale (NIHSS) of 0. A computed tomography (CT) scan of the head was unremarkable. Computed tomography angiography (CTA) of the brain/neck were unremarkable. The symptoms improved significantly while she was in the emergency department. She was admitted to the hospital with plans to obtain a magnetic resonance imaging (MRI) scan of the brain. The MRI of the brain was unremarkable. An electroencephalogram (EEG) did not reveal epileptiform activity. The patient was discharged with plans for outpatient follow-up. At issue is the medical necessity of an inpatient stay.

Based on the clinical documentation provided, evidence-based literature and standards of care, acute inpatient level of care was not medically necessary for the entire admission. Evaluation and management could have been performed at a lower level of care.

The patient had no significant medical history and presented with left-sided weakness and numbness. The initial examination documented an NIHSS (National Institute of Health Stroke Scale) of 0. An extensive evaluation including laboratory testing, computed tomography (CT) imaging, magnetic resonance (MR) imaging, and an electroencephalogram (EEG) were essentially unremarkable. Aspirin was prescribed. No other issues or complications were documented. The patient was deemed medically stable and was discharged the same day.
The clinical indications for admission to inpatient care were not met. The patient did not have hemodynamic instability, recurrence of focal neurologic signs, finding on brain imaging that requires inpatient care (eg, mass), altered mental status, cardiac arrhythmias of immediate concern, clinically significant cardiac or vascular disorder identified that require inpatient care (eg, severe valvular disease, arterial dissection), severe hypertension systolic blood pressure greater than 180 millimeters of mercury (mmHg) or diastolic blood pressure (DBP) greater than 120 mmHg), prolonged cardiac telemetry monitoring needed beyond observation care time frame, suspected vasculitis, pregnancy, or parenteral anticoagulation required due to embolic etiology concern (eg, atrial fibrillation, intracardiac thrombus) and inpatient anticoagulation is needed (eg, contraindications to oral regimens such as severe thrombocytopenia, liver disease with coagulopathy, advanced renal failure).[2]