Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder 
Treatment: Inpatient Hospital
The insurer denied inpatient stay. 
The denial is upheld in whole. 

The patient is a male who presented to the emergency department with concerns of left leg numbness and blurry vision. Pertinent history included diabetes mellitus and hyperlipidemia.

The patient had a National Institutes of Health Stroke Scale (NIHSS) of one. Computed tomography (CT) of the head revealed a chronic right cerebellar lacunar infarct, but no acute intracranial hemorrhage or mass effect. No tissue plasminogen activator (tPA) was administered. The patient was admitted with an impression of transient ischemic attack (TIA)/cerebrovascular accident. Treatment plan included aspirin, statin, carotid ultrasound, echocardiogram, magnetic resonance imaging (MRI) of the brain, and consultations. Neurology consultation was obtained, who had an impression of a transient ischemic attack with resolved left leg weakness. Recommendations were for an MRI of the brain. MRI of the brain revealed chronic tiny posterior right cerebellar and right paramedian pontine infarcts, but no acute intracranial pathology. The patient's presenting left leg weakness remained unresolved. The patient was deemed medically stable and discharged with a diagnosis of transient ischemic attack.

The subject under review is the medical necessity for an inpatient stay.

No, the inpatient stay was not medically necessary based on the clinical documentation provided, evidence based literature, and standards of care.

Simmons, et al provided clinical recommendations for the diagnosis and evaluation of a transient ischemic attack. These guidelines suggest all patients presenting with symptoms of possible TIA should undergo urgent evaluation including neuroimaging, cervicocephalic vasculature imaging, and electrocardiography. They also note that echocardiography, prolonged cardiac monitoring, and routine blood tests are reasonable in the evaluation of TIA. In addition, patients with TIA who present within 72 hours of symptom resolution should be hospitalized if they have an ABCD2 (age, blood pressure, clinical presentation, diabetes mellitus, duration of symptoms) score of 3 or greater, have evidence of focal ischemia, or are unable to complete outpatient workup within 48 hours. [1] In this particular situation, the patient had an ABCD2 score of 3 or greater and thus initial evaluation in at least the emergency department and subsequent monitoring was indicated.

An inpatient stay was not medically necessary. The patient did not have hemodynamic instability, focal neurologic signs or symptoms that persist or recur, immediate inpatient procedure needed (e.g., endarterectomy), cardiac arrhythmias of immediate concern, clinically significant cardiac disorder identified that requires inpatient care (e.g., severe valvular disease, cardiomyopathy, atrial myxoma), or severe hypertension that persists past the observation time frame requiring inpatient treatment. In addition, the patient did not have parenteral anticoagulation required as indicated by temporary subtherapeutic anticoagulation unacceptable (e.g. embolic, venous thromboembolism [VTE] within past 12 months, underlying malignancy, mechanical heart valve, known hypercoagulable state), and a contraindication to use of direct thrombin inhibitor (e.g., dabigatran) or oral coagulation factor Xa inhibitor (e.g., rivaroxaban, apixaban) is present (e.g., severe thrombocytopenia, allergy, creatinine clearance [CrCl] less than 30 milliliters per minute (mL/min)/1.73meters squared (m2), pregnancy, liver disease with coagulopathy, or mechanical heart valve). [2] The patient could have been managed at a lower level of care status.