Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Transient ischemic attack.

Treatment: Inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.

The denial is overturned. 

This female patient has a medical history of diabetes mellitus, hypertension and gastric bypass surgery. The patient was seen in the Emergency Room (ER) for not feeling well, dizziness, and numbness of the left arm and leg which resolved while in the ER.  In the assessment it was noted the possibility of cerebral ischemia versus transient ischemic attack (TIA). The plan was to do computed tomography scan (CT) scan of the head and labs and likely admit the patient to the hospital. It was noted that the patient had similar events in the past. The neurological exam was normal. The plan was to admit the patient for the diagnosis of transient ischemic attack (TIA). There is discharge documentation that the patient had a CT scan and magnetic resonance imaging (MRI) which were negative for stroke and that she felt better and was going to be discharged home. 

As per Talwalkar et al. (2015), "Stroke is the fifth leading cause of death in the United States. About 87% of all strokes are ischemic strokes. Transient ischemic attacks (TIAs) cause similar symptoms, but the blockage of blood flow to the brain is temporary.  However, about one-third of people who have a TIA will have a stroke within 1 year. Emergency departments play a critical role in the diagnosis and management of ischemic stroke and TIA. The evaluation of these conditions in the emergency department is similar, so they are combined for this analysis. This report presents recent trends in visits to emergency departments for ischemic stroke or TIA."

As per Kapral et al. (2016), "Patients with minor ischemic stroke or [transient ischemic attack (TIA)] discharged from the [Emergency Department (ED)] are less likely than admitted patients to receive timely stroke care interventions.  Among discharged patients, referral to a stroke prevention clinic is associated with improved processes of care and lower mortality.  Additional strategies are needed to improve access to high-quality outpatient TIA care." 

As per Silver et al. (2016), "An estimated 5 million people in the United States have experienced a TIA. Most of these people visited an emergency department for their immediate evaluation and treatment.  The decisions regarding what investigations will be performed, what treatments will be initiated, and in what setting these events will occur vary greatly across the country."

Based on the review of the medical record and literature, this inpatient admission is considered medically necessary for this patient. The patient presented with stroke versus TIA and admission with further workup and management is needed in her case. The patient had symptoms concerning for brainstem stroke including dizziness and numbness. This type of stroke is life threatening as sometimes the patient presents with heralding stroke (minor stroke) that can be quickly followed by a more severe stroke that can be lethal. When this type of stroke is suspected, the patient should be admitted to inpatient so they have quick access to life saving interventions should this occur

The health plan did not act reasonably with sound medical judgment and in the best interest of the patient. 

The medical necessity is substantiated. The health plan's denial of the request for the inpatient hospital admission is overturned.