Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Transient Ischemic Attack (TIA)

Treatment is an inpatient admission 

The insurer denied coverage for an inpatient admission 
 
The denial is upheld

The patient presented to the emergency department (ED) with severe and progressive dizziness with slurred speech, numbness, right facial droop and chest pain. 

The emergency department (ED) note states that she was admitted for dizziness in the past and diagnosed with iron deficiency anemia. She now has chills, rigors and subjective numbness and episodes of slurred speech. The exam shows no abnormalities. She was admitted for a transient ischemic attack (TIA) work up. The discharge summary states that the discharge diagnosis was anemia, dizziness and TIA.

During the hospitalization, vital signs were normal. The oxygen level was normal. Laboratory evaluations were normal. Imaging of the brain was normal including an MRI (magnetic resonance imaging) of the brain and a CT (computed tomography). The exam was without significant abnormalities. No unstable condition that would warrant admission.

"Sudden neurologic dysfunction caused by focal brain ischemia with imaging evidence of acute infarction defines acute ischemic stroke (AIS), while an ischemic episode with neurologic deficits but without acute infarction defines transient ischemic attack (TIA)". (Mendelson, S. J., & Prabhakaran, S. 2021).

"Transient Ischemic Attack (TIA) if untreated carries a high risk of early stroke and is associated with poorer long-term survival [1]. There is emerging evidence of a reduction in stroke risk following TIA. Time critical investigations and management, as well as service organization remain key to achieving good outcomes. Patients are diagnosed with a TIA if they have transient, sudden-onset focal neurological symptoms which usually completely and rapidly resolve by presentation. The tissue-based definition of TIA guides the fact that patients with residual symptoms should be considered as potentially having a stroke, with urgent evaluation regarding eligibility for thrombolysis and/or endovascular clot retrieval (ECR). Essential investigations for all patients with a TIA should include early brain imaging, ECG (electrocardiogram), and carotid imaging in patients with anterior circulation symptoms. (Clissold, B., et al., 2020).

"Purpose of review: This article reviews the diagnosis, investigation, and recommended management after a transient ischemic attack (TIA) and discusses how to make an accurate diagnosis, including the diagnosis of mimics of TIAs. 
Recent findings: 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 CT, CT angiography, carotid Doppler ultrasound, and MRI is an important part of the diagnostic assessment. Treatment options include anticoagulation for atrial fibrillation, carotid revascularization for symptomatic carotid artery stenosis, antiplatelet therapy, and vascular risk factor reduction strategies. 
Summary: TIA offers the greatest opportunity to prevent stroke that physicians encounter. A TIA should be treated as a medical emergency, as up to 80% of strokes after TIA are preventable". (Coutts S. B. 2017).                                                         
   
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 hospital admission is not substantiated.