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 regarding the denial of coverage for hospital stay.  The records indicated the patient presented to the emergency department with complaints of slurring of speech for 2 days. The triage notes stated that in addition to slurred speech, the patient had facial droop to the left side.  The patient had a history of left breast cancer from a week prior and claimed to feel dizzy for 2 days.  The patient's blood pressure was 168/84 with respirations 17, heart rate 96, temperature 98, and pulse oximetry 100%.  At the time of the assessment, the patient was not in distress and was awaiting further workup.  The computed tomography (CT) brain report indicated the initial stroke alert was canceled because the patient was out of the window for tissue-type plasminogen activator (tPA).  The report noted that intracranial segments of the internal carotid artery (ICA) were patent without hemodynamically significant stenosis, occlusion, or aneurysm.  In addition, the ICA bifurcations were unremarkable.  There were no abnormalities indicated.  A CT of the chest showed no acute pulmonary disease.  A decision was made to admit the patient for further workup/care.  The patient remained on inpatient status whereupon their condition improved, and she was subsequently discharged.  

The patient received a notice of adverse determination regarding the inpatient stay indicating that the level of care was not medically necessary.  An appeal was submitted claiming that the patient was high risk and presented with symptoms of a transient ischemic attack.  The claim was that the severity of a transient ischemic attack (TIA) should not be diminished based on the presence of reversible symptoms.  The appeal letter stated that an episode of acute neurologic change caused by ischemia of the brain is an indication of the brain at high risk for permanent severe injury.  Inpatient admission with continuous cardiac monitoring and mobilization of specialty and ancillary services was medically necessary to detect and prevent any adverse outcomes. 

According to the Milliman Care Guidelines, clinical indications for admission to inpatient care for those showing signs and symptoms of a transient ischemic attack (TIA) include hemodynamic instability, focal neurologic signs recurring, findings on brain imaging that require inpatient care, altered mental status, cardiac arrhythmias of immediate concern, clinically significant cardiac or vascular disorders identified (e.g., on echocardiogram, imaging) that requires inpatient care (e.g., severe valvular disease, atrial myxoma, arterial dissection), Severe hypertension (systolic blood pressure (SBP) greater than 180 or diastolic blood pressure (DBP) greater than 120, or greater than the 95th percentile for age, gender, and height plus 30 in pediatric patients, prolonged cardiac telemetry monitoring needs, suspected vasculitis, pregnancy, or went parenteral anticoagulation is required.  In the case of this patient, while the patient presented with symptoms of a TIA, the patient responded to treatment and had negative findings on imaging.  Given the provided information, the patient's care could have been safely and effectively rendered on an observational basis with the availability of placing the patient's in observation status if the patient's condition deteriorated requiring a higher level of care.  After a review of the clinical documentation and in reference to the Milliman Care Guidelines, it was determined that the hospital stay was not medically necessary.

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 hospital stay is not substantiated.