Appeal type: Medical necessity
Decision: Upheld

Central Nervous System / Neuromuscular Disorder
Inpatient Hospital

The patient is a male with a history of diabetes who presented to the emergency department with a chief complaint of abdominal pain and paresthesias to the arms and legs on the left side. A stroke alert was called, and the patient was evaluated per stroke protocol. Symptoms started 34 minutes before arrival with acute epigastric pain rated 5 out of 10 on the pain scale and was non-radiating. The patient went to the bathroom to have a bowel movement and noticed the left lower extremity was weak, and he was unable to walk. He kept leaning towards the left side and felt very unsteady. The abdominal pain resolved with a bowel movement, but the weakness persisted. On arrival, the National Institutes of Health (NIH) stroke score was 1. Vital signs included a temperature of 98.3, heart rate of 79, and blood pressure of 122/81, with 100% oxygen saturation on room air. On exam, the patient was cooperative and pleasant with a normal cardiovascular and pulmonary exam. Overall, the neurologic exam was unremarkable except for unsteady gait and deviation left toe to heel gait.

Computed tomography (CT) scan of the brain was negative for intracranial pathology. He was admitted to the hospital under the suspicion of acute CVA. The laboratory studies showed normal hemoglobin and white blood cell count as well as normal platelets. International normalized ratio (INR) was 1.0, which was stable. There were no electrolytes and renal dysfunction.
The admission history and physical places the admitting diagnosis as transient ischemic attack (TIA). Vital signs remained unremarkable. The patient was started on aspirin. Echocardiogram and carotid ultrasound were ordered for further evaluation.
The following day the neurology team evaluated the patient. Vital signs remained stable. They noted that the symptoms lasted for about 3 hours and that he was 97% back to normal. The neurologic exam was unremarkable. Echocardiogram showed normal ejection fraction, no wall motion abnormalities, no mention of intracardiac thrombus. The neurologist recommended obtaining a brain magnetic resonance imaging (MRI), magnetic resonance angiography (MRA) and carotid duplex.
The patient remained comfortable in no overt distress. The brain MRI showed no acute infarct nonspecific scattered foci of T2 prolongation in the supratentorial brain. The MRA showed the left intracranial vertebral artery not seen either due to hypoplasia or stenosis. The patient was continued on aspirin and statin therapy. The neurology team reevaluated the patient and did not recommend additional workup based on the MRI results. 

The health plan's determination is upheld.

The requested health service/treatment of inpatient stay is not medically necessary for this patient. The patient could have been appropriately managed at a lower level of care status.
This patient did not suffer an acute CVA, as evidenced by the imaging studies of negative head CT, negative MRI of the brain. He did not have hemodynamic instability, hemodynamically significant stenosis of the carotid arteries, cardiac arrhythmias. There is no evidence of brain mass, arthritis, altered mental status. The patient did not experience severe hypertension that required an intravenous or continuous infusion of antihypertensive medications. The patient did not need anticoagulation for the condition. The appropriate evaluation with brain imaging, echocardiogram, and carotid duplex can be accomplished quickly with similar outcomes without the need for an inpatient stay. This is a typical transient ischemic attack presentation, which is readily manageable under a lower level of care status.