Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

The patient is a female with a past medical history significant for hypothyroidism, and sciatica who presented to the emergency department with right-sided weakness and dizziness that started on the day of admission. The patient described the sensation of warmth and fullness in her face, hand, behind the right ear.
At the time of the exam performed by the admitting physician, the patient's National Institute of Health (NIH) score was 2. 
When seen by the admitting physician, the patient was afebrile. 
On the neurological exam, the patient was alert and oriented x 3. The patient followed commands. She had right-sided hemiparesis.
Computed tomography (CT) scan of the head showed no acute intracranial abnormality. Magnetic resonance imaging (MRI) of the brain showed no acute findings. MRI of the cervical spine was also performed and demonstrated no significant spinal canal stenosis or neural foraminal narrowing.
During the hospital stay, the patient's right-sided weakness improved. In the hospital, the patient received treatment with aspirin and statin. According to the discharge summary, it was concluded that the patient had a transient ischemic attack (TIA).
Before the discharge the patient also underwent transesophageal echocardiogram (TEE). The study did not reveal clinically significant abnormalities. 
The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care. Based on the medical records, this patient was admitted to the hospital with acute onset of neurologic symptoms that were most consistent with TIA.
According to the nationally accepted standards of care, the acute inpatient level of care is generally indicated in cases of a transient ischemic attack associated with hemodynamic instability, persistent or recurrent focal neurologic signs, in cases when TIA is suspected but an acute stroke is diagnosed.
The admission at the acute inpatient level of care is also required for patients with TIA associated with altered mental status, cardiac arrhythmias of immediate concern, a clinically significant cardiac disorder such as severe valvular disease, atrial myxoma, cardiomyopathy, cases of severe hypertension that could not be controlled by the emergency department or at the observation level of care, certain cases when patients require inpatient procedure or surgery such as endarterectomy, also in cases when parenteral anticoagulation or administration of antiplatelet agents is required.
The review of the medical records clearly demonstrated that in this clinical case the patient had no circumstances listed above.
This determination coincides with Milliman Care Guidelines (MCG) Health Inpatient & Surgical Care 25th Edition Inpatient and Surgical Care 25th Edition criteria for Transient Ischemic Attack. There was no evidence that these criteria were applicable in this clinical case to justify admission at the acute inpatient level of care.
The admission to monitor the patient was definitely indicated, however this could have been accomplished at a lower level of care status.