Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Transient ischemic attack. 
Treatment: Inpatient admission. 

The insurer denied coverage for the inpatient admission. 

The denial is upheld. 

This is a female patient who presented to the Emergency Department (ED) with a chief complaint of numbness for 1 week. The patient's past medical history was significant for transient ischemic attack (TIA) as well as chronic kidney disease (CKD) stage II-III with creatinine at 1.18 (baseline) as well as hyperlipidemia. The patient complained of numbness to the whole left side of the face. The patient reported that the week prior, she was admitted to the hospital for a TIA with left-sided numbness as well as weakness and shortness of breath. The patient's symptoms resolved and she was recommended to be seen by neurology as an outpatient. The patient reported that she had been utilizing the previously recommended medication but, on the morning of this ED presentation, she felt numbness and tingling on the left side of her face as well as to her left arm and leg. 

In the ED, the patient's physical examination revealed that she was alert and oriented.  The patient had a blood pressure of 120/81 and pulse of 95. The patient had normal range of motion. There was decreased sensation over the left side of the face, left arm and leg. There was no weakness and there was normal coordination. It was recommended that the patient undergo a computed tomography (CT) scan of the head. The documentation indicated that the patient also underwent laboratory studies. The patient's laboratory studies did not reveal any significant abnormalities. The patient also underwent an electrocardiogram (EKG) revealing a normal study with a heart rate of 60. The patient's CT scan did not show any acute infarct or hemorrhage. It was recommended that she undergo a magnetic resonance imaging (MRI) scan of the brain. The patient's MRI was negative. The patient was admitted for TIA evaluation and continued with additional treatment. The patient was consulted by neurology and it was noted that the event was most likely right subcortical sensory presentation. Given the lack of further significant adverse events while hospitalized, the patient was discharged on day 3 of admission with instruction to follow-up as outpatient. 

Based on the review of the medical record and literature, the inpatient admission was not medically necessary for this patient. The patient developed left-sided numbness with no other focal neurological examination with negative head CT scan and MRI.  According to the provided records, there is no clear evidence of an acute change in the patient's neurological examination suggestive of an acute stroke. The patient did not exhibit acute motor, sensory or visual deficit(s) that suggested an acute stroke. There was no instability, new focal neurological signs, acute stroke, hemodynamic or cardiovascular compromise or acute prolonged metabolic decompensation or seizure. 

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient. 

The carrier's denial of coverage for the inpatient admission should be upheld. The medical necessity is not substantiated.