Appeal type: Medical necessity
Decision: Upheld

This is a patient with a past medical history significant for a cerebrovascular accident (CVA) with residual right sided weakness, diabetes mellitus (DM), hypertension (HTN), hyperlipidemia, depression, and anxiety. She presented to the emergency department (ED) with slurred speech, dysphagia, and word finding difficulty. She was in her usual state of health when she went to bed. She was on the phone with her daughter the following morning and the daughter noted that she was slurring her speech and thus advised her to go to the ED. She had no change in her usual right sided weakness but did complain of a posterior headache. 

In the emergency room (ER), her blood pressure was 190/115, she had a pulse of 87, a respiratory rate of 18, and an oxygen saturation of 97% on room air. Her blood sugar was in the low 80's. On exam, she was emotional, crying at times. She was alert and oriented x 3. She was slurring her speech, however, there was no documentation of slurred speech on the history and physical (H&P). There was decreased right muscle strength, which was known. The patient's abnormal blood work included a mildly elevated creatine phosphokinase (CPK) of 252 and a creatinine of 2. A computed tomography (CT) scan of the brain was completed which showed no acute abnormalities. The patient was admitted to telemetry for a possible stroke. 

The health plan's determination is upheld. 

The patient was admitted to telemetry for a possible stroke. She was continued on Aspirin, Plavix, and a statin. There were no plans for tissue plasminogen activator (TPA) as the timing of her symptoms was unknown. Her vital signs were monitored and she had frequent neurologic checks. She was seen in consultation by Neurology who recommended a magnetic resonance imaging (MRI) scan of the brain and an electroencephalogram (EEG). The patient remained in stable condition and her blood pressure improved. She was seen by the social worker, and there was no mention of active dysarthria. The patient did not want to wait for an MRI scan or an EEG and signed out against medical advice. She was yelling at staff and was seen using her cell phone. The final diagnosis on the discharge summary was a transient ischemic attack (TIA). The discharge summary had no mention of any ongoing dysarthria or aphasia and stated that her condition on discharge was stable. 

According to the American Heart Association in a Stroke publication from March 2006, patients with a transient ischemic attack do not need to be admitted to a hospital for urgent evaluation and treatment, but often are due to the absence of an alternative. There have been TIA clinics popping up for this purpose. The patient does not meet Milliman Care Guideline M-83 for an acute stroke as the imaging that was done did not indicate an acute stroke and there was no documentation of ongoing acute focal neurologic findings to support the diagnosis. The patient also does not meet Milliman Care Guideline M-360 for a TIA as there was no hemodynamic instability, no evidence for acute stroke on imaging, no evidence that acute focal neurologic signs or symptoms persisted, no need for urgent surgery, no other finding on imaging such as a brain mass, no altered mental state, no cardiac arrhythmias, and no uncontrolled hypertension that could not be controlled in an observation period of time. In this case, based on Milliman guidelines, this patient was appropriate for a lower level of care.