Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory Problems
Inpatient Hospital

Diagnosis: Transient Ischemic Attack (TIA)
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The health plan's determination is upheld.

The patient is a female with history of hypothyroidism who presented to the emergency department with concerns for left-sided weakness. The initial examination documented the patient as alert and oriented with a National Institute of Health Stroke Scale (NIHSS) of 1 due to left-sided weakness. Initial laboratory testing unremarkable.
The electrocardiogram (EKG) unremarkable. The computed tomography (CT) of the head unremarkable. The computed tomography angiography (CTA) of the brain and neck was unremarkable. The patient was placed in the hospital thereafter with an impression of a transient ischemic attack. The treatment plan included an echocardiogram, magnetic resonance imaging (MRI) of the brain, and therapy services. The presenting symptoms had resolved without recurrence. Neurology was consulted and documented an NIHSS of 0. Recommendations were to discontinue Plavix and obtain an MRI brain. The echocardiogram was unremarkable. The MRI of the brain was negative. 

Based on the clinical documentation provided, evidence based literature and standards of care, acute inpatient level of care was not indicated as medically necessary for the entire admission. Evaluation and management could have been performed at an alternate level of care, with transition to outpatient services.
Simmons et al. provided clinical recommendations for the diagnosis and evaluation of a transient ischemic attack. These guidelines suggest all patients presenting with symptoms of possible transient ischemic attack (TIA) should undergo urgent evaluation including neuroimaging, cervicocephalic vasculature imaging, and electrocardiography. They also note that echocardiography, prolonged cardiac monitoring, and routine blood tests are reasonable in the evaluation of TIA. In addition, patient with TIA who present within 72 hours of symptom resolution should be hospitalized if they have an age, blood pressure, clinical presentation, diabetes mellitus, duration of symptoms (ABCD2) score of 3 or greater, have evidence of focal ischemia, or are unable to complete outpatient workup within 48 hours.[1]
The patient had a history of hypothyroidism who presented with left-sided weakness. A comprehensive evaluation was performed including laboratory testing, CT head imaging, echocardiography, and MRI brain imaging which were all essentially unremarkable. No urgent treatment or intervention was performed or recommended. Presenting symptoms resolved and did not recur. Following observation care, the patient was at baseline and discharged. No other issues or complications were documented.
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 (e.g., mass), altered mental status, cardiac arrhythmias of immediate concern, clinically significant cardiac or vascular disorder identified that requires inpatient care (e.g., severe valvular disease, arterial dissection). The patient did not have severe hypertension systolic blood pressure (SBP) 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 (e.g., atrial fibrillation, intracardiac thrombus) and inpatient anticoagulation is needed (e.g., contraindications to oral regimens such as severe thrombocytopenia, liver disease with coagulopathy, advanced renal failure).[2]
 
The health plan's determination of medical necessity is upheld in whole.