Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Transient Cerebral Ischemic Attack
Treatment: Inpatient admission stay
The health plan denied: Inpatient admission stay
The determination is: Upheld

The patient is a male with a medical history of hypertension, rheumatoid arthritis, and former tobacco use, who presented to the emergency department (ED) from home with episodes of right leg and arm weakness accompanied by slurred speech. He reported experiencing three such episodes on the day of the presentation, each lasting about 20 minutes, and associated with word-finding difficulty. These symptoms had also occurred during the week but lasted for only 5-10 minutes. The patient denied facial expression problems and sensory issues in the extremities or face. He denied palpitations, arrhythmias, dizziness, diaphoresis, visual changes, headaches, or other concerning symptoms. Notably, the patient had no family history of cardiac arrest, palpitations, arrhythmias, or heart problems, and all family members were alive. He admitted to experiencing nocturnal agonal respiration and dyspnea-related panic episodes 2-3 times per week. The patient denied any syncope episodes and had not previously seen a cardiologist but had regular follow-ups with his primary care physician (PCP).

Upon arrival at the ED, the patient's initial vital signs were stable. A stroke code was called, and a computed tomography (CT) scan of the head showed no acute abnormalities but revealed age-related cortical atrophy and white matter disease. Computed tomography angiography (CTA) of the head and neck showed no significant stenosis or aneurysm. 

The patient had intact sensation and motor strength in all extremities, but he reported numbness in the right leg from the knee to the toe, including the plantar region. Neurologically, he was alert and oriented, and his speech was intact without slurring.
The CTA findings were unremarkable for significant stenosis or aneurysm. The patient was admitted to the stroke unit with telemetry monitoring. Further investigations and management were planned, including a non-contrast brain magnetic resonance imaging (MRI), echocardiogram (ECHO), electroencephalogram (EEG), and telemetry monitoring for Brugada pattern on electrocardiogram (EKG), fasting lipid profile, thyroid function test (TFT), and hemoglobin A1C (HbA1C). 

The patient was offered a loop recorder for further monitoring of his condition. Additionally, the decision was made to perform Holter monitoring upon discharge and schedule outpatient follow-up at the cardiology clinic. 

The MRI of the brain revealed small areas of restricted diffusion in the left frontal cortex and subcortical white matter, as well as the left caudate and putamen, consistent with an acute/subacute infarct. There was no evidence of acute hemorrhage or mass effect. To manage the cerebrovascular accident, the patient was prescribed acetylsalicylic acid (ASA), Plavix, and Lipitor therapy. During the hospital stay, the patient remained in stable clinical condition. He was advised to follow up with his primary care physician and cardiology within one week after discharge.

At issue is the medical necessity of the inpatient stay.

The health plan's determination of medical necessity is upheld in whole.

The inpatient stay was not medically necessary. The patient did not meet the typical criteria for acute inpatient care for acute ischemic stroke. There were no neurologic findings, hemorrhagic transformation, altered mental status, dysphasia, aphasia, or gait impairment. Brain imaging showed no edema or large infarction, and there was no evidence of hemodynamic instability, cardiac arrhythmias, respiratory abnormalities, severe uncontrolled hypertension, or the need for urgent procedures or parenteral anticoagulation. The patient did not need prolonged cardiac telemetry monitoring beyond 24 hours. There was no need for any urgent procedures such as thrombectomy or thrombolysis.