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 adult male was transported via emergency medical services (EMS) with complaints of slurred speech, weakness and difficulty ambulating. The patient noted his left upper extremity kept dropping when he tried to lift it. The patient has been in the Emergency department (ED) four days prior for left sided headache and diagnosed with shingles. The patient was prescribed Valacyclovir and Erythromycin 0.5% (percent) Ophthalmic. Past medical history (PMH) was significant for Hypertension, Type II diabetes and Overweight (Body Mass Index [BMI] 27.1). Medications prior to admission included Amlodipine, Lisinopril, Glipizide, Metformin, Actos, Meclizine and Pepcid. The emergency department evaluation  noted vital signs were: Blood pressure 161/84, Temperature 98.8 degrees, Pulse-85, Respirations-16; oxygen saturation 100% on room air. There were noted vesicular lesions on the left side of the face. Labs noted glucose 84, and computed tomography (CT) Head showed ventricles and sulci compatible with a component of involutional change and mild periventricular hypodensity; chest X-Ray was unremarkable. Electrocardiogram (EKG) noted Normal Sinus Rhythm. Treatment included contact isolation was maintained; Intravenous (IV) Normal Saline 1 liter bolus; Cerebrovascular accident (CVA) risk factors- Neurology evaluation noted transient ischemic attack (TIA) vs. (versus) CVA; Shingles.  The admission treatment recommendations included telemetry, neuro checks every (q) 2 hours, Fall/Aspiration/Seizure Precautions, statin, Dual antiplatelet therapy (DAPT), aspirin, Plavix, magnetic resonance imaging (MRI) Brain, carotid ultrasound (CUS) and labs; consider Ophthalmology Consult to rule out (R/O) Herpes Zoster Ophthalmic.  The MRI Brain noted mild chronic cerebral small vessel changes. Carotid ultrasound (US) was negative. Ophthalmology Evaluation noted Herpes and an inferior epithelial defect, which might be neurotropic and should be treated with Erythromycin ophthalmic ointment to be applied to the left eye every 3 hours to encourage healing. Neuro follow-up noted TIA and continued statins and Plavix 21 days. The patient was discharge stable, voiding, ambulating. The discharge recommendations were for outpatient follow-up with his private ophthalmologist; follow up with Neurology within one week.

Per the cited references, many factors contributed to decisions regarding admitting a patient with TIA; however, clinicians' uncertainty appeared to be a key driver. Based on the clinical documentation, the patient did not exhibit severe problems to warrant inpatient admission therefore, full hospital admission is not considered medically necessary for this patient. He could have been treated at an observation level of care.

Per the Milliman Care Guidelines 27th Edition using the guideline of Transient Ischemic Attack (TIA) ORG: M-360 (ISC) Care Planning - Inpatient Admission criteria is supported for one of the following: 

Hemodynamic instability: Focal neurologic signs recur; Finding on brain imaging that requires inpatient care (e.g., mass); Altered mental status; Cardiac arrhythmias; Severe hypertension; Prolonged cardiac telemetry monitoring needed (e.g., beyond observation care time frame); Suspected vasculitis; Pregnancy. The documentation did not support a severe indication to support a full hospital admission.  

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 full hospital admission is not substantiated.