Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Transient Ischemic Attack (TIA)

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is overturned.

This female patient has a past medical history significant for diabetes, hypertension, hyperlipidemia, and thyroid disease.  The patient presented to the Emergency Department (ED) with subjective complaints of chest pain, severity of 4/10 with radiation to the left arm.  The patient also reported left-sided weakness and dizziness.  The patient noted that she had a headache for a few hours and had dizziness and numbness almost 2 years ago. The patient's computed tomography angiography (CTA) of the head with contrast and CTA of the neck revealed no significant stenosis in the intracranial arterial vasculature and no significant stenosis in the cervical arterial vasculature.  The stroke team recommended tissue plasminogen activator (TPA), but the patient declined.  The patient's laboratory studies showed troponin <0.010 ng/mL, and venous pH 7.160, PCO2 64.6 mmHg, PO2 <40 mmHg, and the base excess was -7.8 mmol/L.  The patient's chest x-ray revealed prominent cardiac silhouette. The patient's initial electrocardiogram (EKG) revealed a normal sinus rhythm, with no ST-T-segment changes.  The troponin was negative x2.  The patient was admitted for further work-up to the stroke service.  The patient was persistently dizzy, unable to stand, and there was concern for posterior fossa pathology.  The diagnostic testing done in the ED showed low likelihood of cardiac, infectious, endocrinology or electrolyte etiology.  The patient underwent a magnetic resonance imaging (MRI) of the brain which was unremarkable.  The patient underwent a neurology consultation and the neurologist noted that given the description of the patient's complaints, the patient should be treated transient ischemic attack (TIA).  The patient underwent a cardiology and occupational therapy (OT) evaluations.  The cardiology notes indicated that it was possible that the patient had a stable angina but her description of complaints was more consistent with a TIA, as per neurology.  The patient was to undergo a stress test as an outpatient.  The patient underwent a transthoracic echocardiogram which showed normal left ventricular systolic function with estimated ejection fraction-60-65%.  It was noted that the patient did not require additional inpatient cardiac testing and she was subsequently discharged.
  
Based on the review of the medical record, the patient was persistently dizzy, unable to stand, and there was concern for posterior fossa pathology.  The testing in the Emergency Department (ED) indicated that a cardiac, infectious, endocrinology and electrolyte causes of her dizziness were less likely.  The patient underwent a magnetic resonance imaging (MRI) of the brain which was unremarkable.  The patient underwent a Neurology consultation who noted that given the description of the patient's complaints, the patient's clinical presentation was most consistent with transient ischemic attack (TIA) event, and should be treated accordingly.  Based on clinical guidelines, this patient had focal neurological deficits which warranted further investigation and monitoring on an inpatient basis. Thus, inpatient admission was medically necessary for this patient.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital admission should be overturned.  The medical necessity is substantiated.