Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems-Stroke/CVA
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan determination.

The patient initially presented to the emergency department with left sided numbness. History included coronary artery disease, hypertension, and hyperlipidemia. Initial examination documented the patient as alert, oriented, with a National Institute of Health Stroke Scale (NIHSS) of 0. Age, Blood pressure, Clinical features of the transient ischemic attack(TIA), Duration of Symptoms, and History of diabetes (ABCD2) of 3. Fingerstick glucose was 114. An electrocardiogram revealed normal sinus rhythm. A computed tomography (CT) scan of the head was unremarkable. A computed tomography angiography (CTA) of the Head/Neck noted a mild narrowing within the cavernous and segments of the bilateral internal carotid arteries. The patient was placed in the hospital thereafter with an impression of transient ischemic attack/rule out stroke. Treatment plan included telemetry, neurological checks, echocardiogram, and magnetic resonance imaging (MRI) of the brain. An echocardiogram revealed a normal left ventricular ejection fraction without a thrombus noted. An MRI of the brain noted minimal white matter ischemic changes without acute ischemia or infarct. The patient was deemed medically stable for discharge to home with a differential discharge diagnosis of TIA versus cervical myeloradiculopathy.

Based on the clinical documentation provided, evidence based literature and standards of care, acute inpatient level of care was not indicated as medically necessary. Evaluation and management could have been performed at a lower level of care.  The patient was hemodynamically stable with an NIHSS of 0 on arrival. An extensive and comprehensive evaluation was performed and was essentially unremarkable. Neurology consultation had an impression of a TIA versus a cervical myeloradiculopathy. The attending physician's examination documented no focal neurological deficits.
Simmons et al. provided clinical recommendations for the diagnosis and evaluation of a TIA. These guidelines suggest all patients presenting with symptoms of possible transient ischemic attack 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 score of 3 or greater, have evidence of focal ischemia, or are unable to complete outpatient workup within 48 hours.[1] In this situation, the patient had an ABCD2 score of 3 or greater and initial evaluation in at least the emergency department and subsequent lower level of care was indicated.
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 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.[2]