Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Transient Ischemic Attack.

Treatment: Inpatient hospital stay.

The insurer denied coverage for inpatient hospital stay.

The denial is overturned.

This case involves an adult patient who presented to the hospital with chief complaints of unsteady gait and numbness/tingling to the right side radiating down the arm for 3 days. The patient stated to have had numbness on the right side of the body and associated clumsiness. The patient reported some mild confusion. The patient had some episodes of slurred speech. The symptoms improved overnight. The patient felt mostly normal but endorsed some neck pain and stiffness with occasional mild headache. The review of systems was positive for neck pain, neck stiffness, tinnitus, speech difficulty, weakness, numbness, and headaches. The exam findings reported tenderness to the cervical spine and decreased strength in the right upper and lower extremity when compared to the left side. The patient's sensation was intact. There was no facial asymmetry. Due to dizziness and numbness, there was a plan to admit the patient for further work-up of transient ischemic attack. An electrocardiogram noted that the patient was in sinus rhythm. It was felt that the patient's decreased strength could be secondary to pain as it improved in 2 hours. The patient's computed tomography of the head was normal. Computed tomography of the cervical spine was normal. Neurology was consulted and recommended 1 dose of methocarbamol and follow-up with the neurology clinic within 1 week of discharge. An echocardiogram showed left ventricular diastolic function that was normal. The ejection fraction was 60 to 65%. The carotid Doppler was normal. The patient received albuterol nebulizer once which corrected the hyperkalemia. The patient was discharged once deemed medically stable.

Per the cited references, admission for transient ischemic attack is indicated when there is hemodynamic instability, focal neurological signs that recur, finding on brain imaging that requires inpatient care, altered mental status, cardiac arrhythmias of immediate concern, when clinically significant cardiac or vascular disorder is identified, for severe hypertension, when prolonged cardiac telemetry monitoring is needed beyond observation care timeframe, and/or when there is suspected vasculitis. In this case, the patient presented to the hospital with complaints of unsteady gait, numbness/tingling to the right side with radiating symptoms that have been ongoing for 3 days, an episode of mild confusion, and episodes of slurred speech. At the time of presentation, the patient reported to have felt mostly normal but had some neck pain and stiffness with occasional mild headaches. On exam, there is decreased strength in the right upper and lower extremities. Diagnostic work-up was unrevealing. It was argued that admission to the hospital was medically necessary for the patient as there was continued concern for transient ischemic attack. The patient needed to be clinically stabilized prior to meeting guidelines for safe discharge. The admission to the hospital was supported in this case. There were reports of slurred speech, right sided numbness, and right sided weakness that raised question of transient ischemic attack, stroke, or intracranial etiology. There was decreased strength on exam suspicious for recurrence of focal neurological signs given prior waxing and waning symptoms. Admission is supported for focal neurological signs that recur. Therefore, the health plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The inpatient hospital stay was medically necessary. Denial of coverage for inpatient hospital stay is overturned. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient hospital stay is substantiated.