Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rule out Stroke/TIA

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission. The denial was upheld.

This patient is a female with a past medical history of hypertension, diabetes type 2, and a hiatal hernia.  The patient presented to the emergency department subjective complaints of numbness to the right side of her face for 45 minutes, and palpitations.  The patient's blood pressure on presentation was 175/103.  The patient's heart rate was 115.  Her respiratory rate was 18 and her temperature was 98.3 F.  The patient's National Institutes of Health (NIH) stroke score was 0.  The patient indicated that the numbness had resolved but she continued to feel palpitations.  The patient denied headaches, weakness, or numbness or tingling in the extremities.  The patient had a troponin of 0.0, a thyroid-stimulating hormone (TSH) of 5.90 patient denied chest pain and shortness of breath.  

The patient underwent laboratory studies which revealed, a hemoglobin A1c of 8.1, and a d-dimer of 0.81.  The patient underwent CT scan of the head which was unremarkable.  The patient underwent a chest x-ray and a Doppler of the lower extremities, which were negative for deep vein thrombosis (DVT).  The patient underwent an EKG which revealed Sinus tachycardia with left axis deviation.  The patient was treated with clopidogrel and potassium.  The patient was admitted to the telemetry unit for a TIA and palpitations.  The patient underwent a neurology and cardiology consultation.  The nuclear medicine ventilation perfusion lung scan showed a low probability of a pulmonary embolus.  The electroencephalogram (EEG) and echocardiogram were normal after admission.  The MRI of the brain was negative.  The patient was stabilized and was discharged.

This case was previously denied by the insurance company.  The rationale for denial indicated that the patient was admitted with a transient ischemic attack (TIA) and palpitations.  

The healthcare plan acted reasonably and with good sound medical judgment and in the best interest of the patient.  The patient presented to the hospital with focal neurologic symptoms of right facial numbness lasting approximately 45 minutes.  Given the symptoms, physicians were concerned for TIA or minor stroke.  The NIH stroke scale was 0 indicating a low level of disability secondary to the symptoms.  Consistent with good practices, the patient underwent a CT scan of the head to evaluate for an acute ischemic process, such as hemorrhage or mass.  Then, the patient was evaluated by MRI to rule out cerebral ischemia.  Secondary risk factors were evaluated.  The patient's TSH, hemoglobin A1c, and lipids were evaluated.  She was treated with an anti-platelet therapy (Plavix). She was monitored for arrhythmia. The patient did not have any significant rehabilitation needs.  As such, the admission did not meet typical standards for acute inpatient admission based on the level of disability and lack of medical findings.

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial is upheld.