Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder - Transient Ischemic Attack (TIA). 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

The patient is a male with a past medical history significant for hypertension and hyperlipidemia who was brought to the emergency department with complaints of weakness and difficulties speaking. His symptoms started several hours before the presentation. The patient denied headache, blurry vision, double vision, chest pain, or shortness of breath. He stated that he felt nauseous early that morning but denied fever and chills.
By the time the patient was seen by the admitting physician his symptoms were almost completely resolved. The admitting physician stated that at the time of the exam he had no focal weakness, and his speech was almost back to normal. It was also reported that before the presentation to the hospital the patient had a facial droop that was not observed by the admitting physician. The remainder of the review of systems was normal.
When the patient was seen by the admitting physician, he was afebrile. Heart rate was 98 beats per minute (bpm), respiratory rate 16 breaths/minute, blood pressure 124/77, oxygen saturation 100% on room air. On the neurologic exam, the patient was alert and oriented times 3. The sensation was intact in the upper and lower extremities. There was normal muscle strength in the upper and lower extremities bilaterally. The rest of the physical exam was unremarkable.
Computed tomography (CT) scan of the head demonstrated no evidence of acute intracranial hemorrhage or acute territorial infarction. CT angiogram of the carotid arteries and circle of Willis was unremarkable. There was no flow-limiting vasculopathy.
The patient was admitted to the hospital and seen by a neurologist who recommended a magnetic resonance imaging (MRI) of the brain. The MRI was performed and came back negative for acute pathology. The patient was started on a low dose of aspirin and the dose of statin was increased. The patient was recommended to continue treatment with his antihypertensive medications. During the hospital stay, the patient remained in stable clinical condition, his symptoms resolved, and he was discharged from the hospital the next day after the day of admission.

The health plan's determination is upheld in whole.

Based on the initial evaluation, the patient was suspected to have transient ischemic attack (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.
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. Specifically, it was clearly indicated that by the time the patient was seen by the admitting physician his clinical condition already significantly improved, close to the baseline.
Therefore the patient could have been safely managed at a lower level of care status.