Appeal type: Medical necessity
Decision: Upheld

Diagnosis: difficulty ambulating, left-sided weakness

Treatment: Inpatient hospital

The insurer denied coverage for inpatient hospital

The denial is upheld

 
The patient presented to the Emergency Department (ED) from home with complaints of acute onset of difficulty ambulating, left-sided weakness, difficulty speaking, blurry vision and left-sided numbness. In the ED, her Blood Pressure was 168/114, Temperature of 36.8 degrees C, Pulse of 96, Respirations 18, and oxygen saturation of 99% on room air. On examination, the patient complained of pain to right posterior head, she was noted to have left-sided facial droop, left arm drift, left upper extremity (LUE) and left lower extremity (LLE) weakness, dysphasia, and difficulty with ambulation. Electrocardiogram (EKG) showed normal sinus rhythm, Computed tomography (CT) head, CT angiography (CTA) Circle of Willis and CT perfusion returned negative. Abnormal laboratory findings include hemoglobin of 8.3, hematocrit of 28.7, and Erythrocyte sedimentation rate (ESR) 29. Intravenous fluid (IVF) with normal saline (NS) at 75 cubic centimeters (cc) an hour initiated. During the stay, further lab studies showed a drop in hemoglobin levels with severe iron deficiency anemia, and she received 1-unit blood transfusion. Her Vitamin B12 level was low at 185. She complained of chest pain and a EKG was performed and showed no signs of ischemia. Magnetic resonance imaging (MRI) of the brain returned negative; echocardiogram showed normal left ventricle (LV) systolic function. As per Neurology, symptoms are not consistent with transient ischemic attack (TIA), and the suspicion was the patient had migraine with aura vs conversion disorder. She denied further neurological complaints and she remained hemodynamically stable and was discharged to home.

The Milliman Care Guidelines (MCG) indicate Inpatient admission for Transient Ischemic Attack (TIA) for 1 or more of the following: Hemodynamic instability, Focal neurologic signs recur, Finding on brain imaging that requires inpatient care (e.g., mass), Altered mental status, Cardiac arrhythmias of immediate concern, Clinically significant cardiac or vascular disorder identified (e.g., on echocardiogram, imaging) that requires inpatient care (e.g., severe valvular disease, atrial myxoma, arterial dissection), Severe hypertension, Prolonged cardiac telemetry monitoring needed (e.g., beyond observation care time frame), Suspected vasculitis, Pregnancy, and Parenteral anticoagulation as indicated by Embolic and Inpatient coagulation needed. 

Although the patient presented with complaints of acute onset of difficulty ambulating, left-sided weakness, difficulty speaking, blurry vision and left-sided numbness, and there was a suspicion of TIA, EKG showed NSR, CT head, CTA Circle of Willis and CT perfusion returned negative. The evaluation can be done in an observation setting per MCG. In addition, Neurology was consulted, and it was determined that the patient's symptoms are not consistent with TIA. The care given to the patient can be provided in a lower level of care or in an observation care. 

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 an inpatient admission is not substantiated.