Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Transient Ischemic Attack (TIA)

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
This patient presented to the emergency department (ED) of South Nassau Communities Hospital with complaints of right sided numbness, accompanied by dizziness, headaches, and blurred vision; symptoms occurred three times that day. Initial screening revealed no arm drift and symmetrical facial movement. The patient had elevated blood pressure at home, for which she was taking lisinopril. Blood pressure on presentation was 174/75. The patient underwent a head computerized tomography (CT) scan on presentation that was negative for acute changes. A CT angiography of the head and neck were negative. A CT perfusion revealed a tiny perfusion defect in the left temporal lobe. The patient was then admitted to an acute level of care. A magnetic resonance imaging (MRI) of the brain was performed, revealing no acute pathology; the patient was diagnosed with a transient ischemic attack (TIA), as her symptoms resolved. There is no documentation of any additional treatment or testing performed other than a chest x-ray. The patient's blood pressure was controlled with oral medications. 

The patient presented with left-sided numbness. The initial evaluation had a possible perfusion defect of left temporal lobe, that was not in the location that would correlate with the patient's symptoms that would emanate from the parietal lobe or basal ganglionic region. However, an acute stroke requires exclusion, and the patient required a brain MRI to rule out a stroke, as her symptoms had normalized. The patient's blood pressure was treated with oral medications. A brain MRI can be performed directly from the emergency department or under observation with discharge occurring once acute stroke was ruled out. Therefore, there is no specific medical necessity for acute hospitalization as the patient had no acute needs. A stroke rule out does not require an acute level of care and can be performed in the emergency department or observation.

Per Taylor, R. S., Opara, N. U., & Burg, J. (2021), "There were 983 patients included in the study. The patients on TIA prophylactic medications prior to coming to the ED made up (60.7% [percent]), and (51.2%) in this group required additional medications during hospital admission. The remaining 162 (39.3%), p=0.001 patients, were not on TIA prophylactic medications prior to presenting in the ED. The patients who required additional medications while in the ED were significantly older (mean +(plus)/-(minus)SD, 68.6 +/-14.0 years versus 62.18 +/- 17.4 years, p=0.001). Following a multivariate analysis, age greater than 60 (CI: 3.52-3.91, p=0.001) and results of the head CT/MRI investigations for any signs of neurological damage, were all found to be independent predictors of longer hospital stay and treatment outcomes. There were no significant differences in the treatment outcome for patients with TIA based on longer hospital stay and extra medication administration in the ED.

Conclusion: In our study, we observed that approximately, 75% of the patients who were on TIA prophylactic medications prior to presenting in the ED with symptoms of TIA were admitted to the hospital for further monitoring, compared to other group of patients who were not on TIA medications. We did also noted that there were no differences in mortality outcome between patients treated and discharged from the ED, versus patients admitted to the hospital for additional treatment."

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 inpatient admission at South Nassau Communities Hospital is not substantiated.