Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Transient Ischemic Attack

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

This case involves a patient who presented to the emergency department via ambulance with complaints of left leg weakness and headaches from the doctor's office. The patient reported loss of consciousness while sitting down the night before. The patient denied nausea and vomiting, photo or phonophobia. Tele neurology was called to rule out acute stroke in case of tissue-type plasminogen activator (t-PA). The patient was not deemed a candidate because of "last well-known about 4.5 hours."  The patient was noted to have drifting into the left upper extremity and left lower extremity. The patient's past medical history includes diabetes, hyperlipidemia, hypertension, carotid artery disease, status post myocardial infarction (MI), questionable seizure disorder and syncope. The current medications were noted as aspirin, Lipitor 40 milligrams (mg), Plavix 75 mg, Jardiance 25 mg, Folvite 1 mg, Cozaar 25 mg, Glucophage 1000 mg, Actos 30 mg and Ozempic once weekly injection.  Emergency room vital signs included: blood pressure (BP) 151 over 81 (151/81); heart rate 84 and regular; respiratory rate (RR) 19; temperature 97.5; oxygen (O2) sats 100 percent (%) on room air. 

The patient was noted to be alert awake and oriented x3 with normal language. The motor exam revealed decreased grip in the left hand but otherwise was 5 out of 5 (5 /5) in all groups in upper and lower extremities.  Sensory exam revealed decreased interest and light touch to in the left upper compared to the right. The computed tomography (CT) brain without contrast was normal. The lab work showed a hemoglobin A1c of 7; glucose 113; troponins were negative; white blood cell (WBC) count 13.2, hemoglobin 9.1, and platelet count 29.  Emergency room department impression included: headache, syncope, possible transient ischemic attack (TIA) referable to the right hemisphere/middle cerebral artery (MCA).  Orders for an magnetic resonance imaging (MRI) brain, magnetic resonance angiogram (MRA) of the head and neck vessels and a stat sed rate were placed. An electroencephalogram (EEG) was ordered and showed a questionable seizure history that is somewhat nebulous. The patient was admitted to telemetry to rule out paroxysmal atrial fibrillation (PAF). The patient had been treated with a dual antiplatelet therapy continue statins.  Chest x-ray was performed, which showed no acute cardiopulmonary process and CT of the brain showed no acute intercranial pathology identified. The patient has a history of stroke and has been treated with Plavix and history of cardiac stent. The emergency department diagnosis were headache and radiating left leg weakness. There was no facial droop. The final diagnoses were cerebrovascular accident unspecified mechanism, syncope unspecified type and TIA. 

In this case, although the patient is noted to have a cardiac history, the clinical findings do not support an indication for admission due to an absence of at least or 1 or more of the following (1, 2): Hemodynamic instability; Focal neurologic signs recur; Finding on brain imaging that requires inpatient care (for example (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). Admission to an observational setting may have been an appropriate level of care pending the course of pending diagnostic work-up. 

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 the inpatient admission is not substantiated.