Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Transient Ischemic Attack (TIA)

Treatment: Inpatient hospital

The insurer denied coverage for inpatient hospital.  The denial is upheld. 

The patient is an adult female who presented to the hospital.  There was a history of hypertension and hypothyroidism.  The patient complained of a throbbing headache followed by left-sided weakness, numbness, and tingling that had been ongoing for 1.5 hours.  Upon arrival to the emergency department, the patient's headache had improved.  However, the extremity symptoms persisted.  The exam reported slight decreased strength in the left upper and left lower extremity compared to the right.  Vital signs of the patient noted blood pressure of 155/79, temperature of 36.6 degrees Celsius, pulse of 64, and respirations of 20.  The patient's oxygen saturation was 100% (percent) on room air.  The patient's exam was non-focal.  The patient continued to have paresthesia in the left upper extremity distally.  There was consideration of subacute to chronic lacune on the left.  There were no acute findings to correlate with symptoms.  This could represent migraine headache.  The paresthesia in the left forearm and hand could be cervicogenic or related to carpal tunnel syndrome.  Computed tomography (CT) of the head was unremarkable.  Computed tomography angiography (CTA) carotid/circle of Willis was within normal limits.  Chest radiograph showed no active pulmonary disease.  CT neuro perfusion showed no evidence of core infarct, hypoperfusion, or penumbra.  Laboratory results noted white blood cell count of 12.3 and absolute neutrophil count of 7.9.  The patient was treated with sodium chloride bolus.  The consulting provider felt that the patient's paresthesia in the left forearm and hand was unlikely due to cerebrovascular disease.  There was a plan to observe for 24 hours and get an inpatient or outpatient echocardiogram to complete cerebrovascular accident work-up.  The patient reported resolution of headache.  They were unable to establish cerebrovascular accident based on imaging.  There was probably transient ischemic attack.  

In this case, the patient presented to the hospital with headache and left-sided weakness, numbness, and tingling.  Work-up was unrevealing.  It was argued that admission to the hospital was medically necessary.  The patient had persistent left-sided weakness/paresthesia.  There was a concern for transient ischemic attack versus cerebrovascular accident.  However, the documentation did not support that there was persistent hemodynamic instability, focal neurological signs that recurred, imaging that required inpatient care, altered mental status, cardiac arrhythmias of concern, clinically significant cardiac or vascular disorder that required inpatient care, severe hypertension, that the patient required prolonged cardiac telemetry monitoring, that there was suspected vasculitis, or that parenteral anticoagulation was required.  

Given the patient's stability, the monitoring, diagnostic evaluation, and treatment could have been conducted at a lower level of care such as observation.

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 a full hospital is not substantiated.