Appeal type: Medical necessity
Decision: Upheld

Central Nervous System / Neuromuscular Disorder - Other
Inpatient Hospital

The patient is a male with a reported history of cerebrovascular accident (CVA), 18 months before presentation, as well as hypertension, who presented to the hospital at 3 AM, with 2 hours of numbness while at work. The numbness is in the left arm, with associated weakness as well. There is also a report of face numbness and a mild headache. The patient is only on atenolol and not taking any aspirin or Plavix. The vital signs included a heart rate of 117, systolic blood pressure of 142, respirations of 18, and an oxygenation rate at 100% on room air. The patient is described as alert and oriented x3, ambulating without difficulty with a normal cardiovascular exam. Neurologically, alert and oriented x3, visual fields intact, pupils' equal round and reactive, no pronator drift, 5 out of 5 strength throughout, with sensation intact. There was no truncal ataxia, and his gait was described as normal. The National Institute of Health (NIH) stroke score was calculated as 1. The patient was given aspirin and admitted to the hospital for further management. Laboratory studies included a white blood cell count of 10.4, hemoglobin of 12.7 and the platelets were normal. Electrolytes were overall fairly unremarkable, mild hyponatremia at 132, normal blood urea nitrogen (BUN) and creatinine, normal liver function tests (LFTs).

By the following day, the patient was lying comfortably in bed, without acute distress and had no further complaints. A carotid ultrasound was negative for carotid artery stenosis. A brain magnetic resonance imaging (MRI) was done, which showed no evidence of restricted diffusion, no evidence of prior infarcts, no periventricular or subcortical white matter disease. A magnetic resonance angiography (MRA) also showed no evidence of intracranial stenosis. The echocardiogram showed normal left atrial size and normal ejection fraction.
The following day, the patient had no complaints and no focal neurologic deficits. A Holter monitor was arranged. Aspirin 81 mg and Crestor were started. His blood pressure was stable, and he was discharged home the following day.

The health plan's determination is upheld.

The requested health service/treatment of inpatient stay is not medically necessary for this patient. This is a presentation of a possible TIA, without evidence of a cerebrovascular accident. The patient does not show signs of hemodynamic instability. The focal neurologic findings resolved relatively quickly. There is no alteration of mental status, and there are no cardiac arrhythmias, there is no evidence of severe hypertension. There is no imaging, to suggest severe carotid stenosis that would require an emergent endarterectomy. The medical team did not use thrombolytics, and there was no need for intravenous heparin. 
Based on the provided documentation, the patient satisfies criteria for care at a lower level for the evaluation and treatment of a possible TIA. It is the typical standard of care, to admit this type of patient presentation into a lower level of care such as an observation unit, perform the necessary neurovascular testing, and if a stroke is ruled out, the patient can be discharged to home.