Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Transient Ischemic Attack
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is overturned

This is an adult male diagnosed with coronary heart disease, hyperlipidemia, hypertension, and myocardial infarction. He came to the emergency department describing weakness and dysarthria. Records indicated the patient complained of altered mental status along with slurred speech, and difficulty getting words out. This had been ongoing for 1 hour before arrival and for about 1.2 hours while in the emergency department. The slurred speech resolved, although he claimed to have associated dizziness. The patient was subsequently admitted with claims that he was at high risk for transient ischemic attack. The patient underwent neurology consultation with hypercoagulable state. Records indicate he had a history of left carotid occlusion, splenic infarct, and myocardial infarction with an implanted defibrillator. He was hemodynamically stable with no facial drooping, weakness of the extremities, or numbness. While in the emergency department, the patient felt improved after about 20 minutes. Symptoms resolved and computerized tomography angiography (CTA) showed no new cerebrovascular accident. A CTA confirmed a left carotid occlusion and noted that the patient was already taking aspirin and Plavix. Physical exam findings noted a positive carotid bruit, the patient was a current every day smoker with a history of cardiac stent along with cholecystectomy.  

There were no reported danger signs such as frequent transient ischemic attacks, severe heart disease, or a need for intravenous medication to treat high blood pressure. The orders given for the patient included continuous cardiac monitoring, neurology consult, cardiology consult, hematology consult, and additional laboratory testing. The patient also started on enoxaparin subcutaneous daily. He was discharged with referrals for outpatient cardiology and neurology follow-ups.

According to the Milliman Care Guidelines (MCG), clinical indications for admission to inpatient care include 1 or more of the following: patients who are hemodynamically unstable, have focal neurologic signs that recur, there are findings on brain imaging that require inpatient care to include a mass, altered mental status, cardiac arrhythmias of immediate concern, when there are clinically significant cardiovascular disorders identified that require inpatient care to include abnormalities noted on echocardiogram or imaging. Additionally, patients who have severe hypertension with systolic blood pressure greater than 180 mmHg (millimeters of mercury) or diastolic blood pressure greater than 120 mmHg, or greater than the 95th percentile for age, gender, and height +30 mmHg in pediatric patients. Inpatient care may be indicated for patients with prolonged cardiac telemetry monitoring needs, when there are suspected vasculitis, pregnancy, or parenteral anticoagulation required.  

In the case of this patient, the records noted that he had computed tomography angiography evidence of a left carotid occlusion. He also presented with altered mental status, which subsequently resolved, but for the increased risk factors to include the patient's age as well as medical and surgical history, the full hospital admission was appropriate and within the standard of care given the patient's clinical presentation.  As such, the full hospital admission is medically necessary.

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 full hospital admission is substantiated.