Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Transient global amnesia (TGA).
Treatment:  Inpatient admission.

The insurer denied coverage for an inpatient admission.  The denial is upheld.

According to the medical records, the patient was seen in the emergency department (ED) with stroke like symptoms. She walked with a steady gait. She presented with amnesia and no memory of the day's events. She had memory impairment with no other neurologic symptoms or signs. Neurology exam was unremarkable, Labs were normal, an MRI (magnetic resonance imaging) of the brain was unremarkable, an EEG (electroencephalogram) was negative. The impression is suspected transient global amnesia (TGA) and mild encephalopathy. The Computed Tomography (CT) scan showed no acute abnormalities. 

The issue is the Denial of coverage for the full hospital admission. She presented with amnesia/loss of memory. The exam showed no abnormality, imaging with no abnormalities, labs were normal, vitals were normal, and the electroencephalogram (EEG) was negative.

"Transient global amnesia (TGA) is a clinical syndrome characterized by anterograde amnesia, mild retrograde amnesia, and confusion up to 24 hours. Most commonly seen in patients older than 50 years, TGA results from the temporary impairment of short-term memory formation. Clinically, patients have time disorientation and often ask repeated questions regarding the day's events. Vomiting, headache, blurry vision, dizziness, and nausea may be present. A physically or psychologically stressful precipitating event, such as emotional stress, significant/ physical exertion, exposure to extreme temperatures, high-altitude conditions, valsalva maneuver, acute illness, or sexual intercourse, is often the cause. The pathophysiology of TGA is not well understood but may be related to impaired venous drainage of the hippocampus. The diagnosis is primarily clinical, but recent studies suggest that magnetic resonance imaging may be helpful. TGA is self-limited and resolves within 24 hours. There is no established treatment for episodes. The lifetime recurrence rate is 2.9% to 23.8%. Recent evidence suggests an association between TGA and migraine headaches as well as takotsubo cardiomyopathy. No apparent increased risk of cerebrovascular events occurs in patients who have had an episode of TGA. There is conflicting evidence as to whether an episode of TGA predisposes to future seizures or dementia." (Sealy, D. et al. 2022).

"Transient global amnesia is an episode of confusion that comes on suddenly in a person who is otherwise alert. This confused state isn't caused by a more common neurological condition, such as epilepsy or stroke.

During an episode of transient global amnesia, a person is unable to create new memory, so the memory of recent events disappears. You can't remember where you are or how you got there. You may not remember anything about what's happening right now. You may keep repeating the same questions because you don't remember the answers you've just been given. You may also draw a blank when asked to remember things that happened a day, a month or even a year ago.

The condition most often affects people in middle or older age. With transient global amnesia, you do remember who you are, and you recognize the people you know well. Episodes of transient global amnesia always get better slowly over a few hours. During recovery, you may begin to remember events and circumstances. Transient global amnesia isn't serious, but it can still be frightening." (Mayo Clinic. 2022).                                                         

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the full hospital admission is not substantiated.