Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right-eye blurriness and syncope.

Treatment: inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld. 

This is an adult male who presented to the Emergency Department (ED) by emergency medical service (EMS) from home with complaints of right-eye blurriness and a 20-minute syncopal episode. Notably, the patient described having an episode of widespread chest pain while at work the day before admission, lasting about 10 minutes, with no radiation and self-resolving. He denied any previous medical history but described being a regular smoker and consuming alcohol daily. In the emergency department (ED) vital signs were Blood Pressure 133/80 millimeters of Mercury (mmHg), Temperature 36.6 degrees Celsius, Heart Rate 82 beats per minute, Respirations 18 breaths per minute, and Oxygen Saturation 98% on room air. 

Physical examination revealed resolved blurry vision. He reported that when he awakened after a syncopal episode, he observed right-sided weakness and face droop. A chest X-ray revealed no signs of acute pulmonary illness. The electrocardiogram (EKG) revealed normal sinus rhythm as well as nonspecific T-wave abnormality. The results of the computerized tomography (CT) head, neuro perfusion, and pulmonary arteries, carotids/Circle of Willis were unremarkable. Magnetic resonance imaging (MRI) of the brain showed no acute intracranial pathology. 

The following deviations were discovered in laboratory tests: White Blood Cell (WBC) count 15.5%, Neutrophil 82.4%, Absolute Neutrophil Count (ANC) 12.7%, Partial Thromboplastin Time (PTT) 22.0, and Ethanol 173.3. Sodium Chloride 0.9% 1 liter intravenous (IV) bolus was given to the patient. 

Per Milliman Care Guidelines (MCG) 27th edition, Transient Ischemic Attack (TIA) admission is indicated for 1 or more 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 of immediate concern; Clinically significant cardiac or vascular disorder identified (e.g., on echocardiogram, imaging) that requires inpatient care (e.g., severe valvular disease, atrial myxoma, arterial dissection); Severe hypertension (SBP greater than 180 mm Hg or DBP greater than 120 mm Hg, or greater than the 95th percentile for age, gender, and height plus 30 mm Hg in pediatric patients; Prolonged cardiac telemetry monitoring needed (e.g., beyond observation care time frame); Suspected vasculitis; Pregnancy. Parenteral anticoagulation (e.g., unfractionated heparin) required (e.g., alternative forms of anticoagulation not appropriate or not feasible), as indicated by ALL of the following: Embolic (e.g., atrial fibrillation, atrial cardiomyopathy, intracardiac thrombus) etiology of TIA suspected; AND Inpatient anticoagulation needed. 

The medical records provided for review do not support the inpatient service being requested. 

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 an inpatient stay is not substantiated.