Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Transient Ischemic Attack (TIA). 

Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is overturned. 

The patient was seen in the emergency room (ER) for code stroke. It was noted that the patient presented with left sided weakness and confusion. It was noted that the patient complained of difficulty breathing and left sided numbness. On exam it was noted that the patient had decreased sensation and strength on the left side. It was noted that the patient did not feel back to normal following the evaluation in the ER and the decision was to admit the patient to the hospital for neuro checks and magnetic resonance imaging (MRI). 

The patient was seen in response to stroke alert. The provider noted that the patient presented to the ER with chest pressure, shortness of breath, left sided numbness, and left sided weakness. The patient initially presented to urgent care and Emergency Medical Services (EMS) was called when the patient manifested signs of stroke. On exam the provider noted the left arm drift and left foot dorsiflexion weakness as well as decreased sensation on the left side. In the impression it was noted that the patient presentation was of unclear etiology. The MRI was negative for acute ischemia. It was noted the next day that the patient was back to baseline with no weakness or sensory loss. The provider recommended telemetry and cardiac workup. 

The history and physical noted that the reason for admission as confusion, left sided weakness, and chest tightness. It was noted that the patient presented to urgent care initially but due to suspected stroke EMS (Emergency Medical Services) was called. It was noted that EMS reported that the patient was very drowsy and difficult to arouse. It was noted that the patient was back to baseline in the ER with resolution of weakness. 

In this case, the admission was indicated. According to applicable guidelines and current peer reviewed literature a presentation with Transient Ischemic Attack (TIA) and symptoms of altered mental status meets criteria for admission. Admission was medically necessary to complete the neurological workup, mainly the MRI of the brain. The patient presented with progressive confusion, reduced level of consciousness, and left sided weakness and chest tightness. A code stroke was called in the ER and the patient NIH (National Institute of Health) stroke scale was 2. The patient was found to have hypokalemia and electrolyte replacement was done. 

"Up to a 10% risk of recurrent stroke exists after a TIA, and up to 80% of this risk is preventable with urgent assessment and treatment. Imaging of the brain and intracranial and extracranial blood vessels using computed tomography (CT), CT angiography, carotid Doppler ultrasound, and MRI is an important part of the diagnostic assessment" (1). 

"In our sample of 8,540 patients, the use of recommended interventions was highest in admitted patients, followed by discharged patients referred to prevention clinics, followed by those discharged without clinic referral. Eight percent of non-admitted patients returned to the hospital with recurrent stroke/TIA within 1 week of the index event" (2). 

"This study included 100 patients, 41 with TIA and 59 with minor stroke. Nineteen (46%) of the TIA patients and 29 (49%) of the minor stroke patients randomized to hospital management, and the remaining 22 TIA patients and 30 minor stroke patients randomized to outpatient-based management" (3). 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient is substantiated.