Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Transient Ischemic Attack (TIA) 

Treatment is an inpatient admission 

The insurer denied coverage for an inpatient admission 
 
The denial is upheld

This case involves a patient diagnosed with supraventricular tachycardia (SVT), who presented to the emergency room with complaints of intermittent headache for the past week, with numbness on his left side. The patient claimed that about an hour prior to his arrival, he was reading when he experienced a sudden onset of weakness and numbness on the left side of his face and left upper extremity.  Upon arrival, symptoms had improved, and he denied vision changes, nausea, vomiting, chest pain, palpitations, and shortness of breath. He no longer had a headache but endorsed having a cloudiness as though he was unable to focus.  Physical exam findings were relatively unremarkable other than an elevated blood pressure reading of 179/94. His total NIH (National Institutes of Health) stroke scale score was 0. A CT (computed tomography) of the head showed no evidence for acute transcortical infarct, hydrocephalus, or acute intracranial hemorrhage or mass-effect. CT angiography of the head with contrast showed no stenosis or aneurysm. Reports indicated the patient was not a tPA (Tissue plasminogen Activator) candidate and was recommended treatment with baby aspirin, for which he was given.  

Literature notes that patients who are suspected of having a transient ischemic attack should be evaluated urgently in a clinical setting where appropriate specialist expertise and imaging are available. Management typically includes aspirin for this immediately and indefinitely, with clopidogrel for the first 21 days), evaluation to identify the cause, and guide interventions as appropriate, with control of risk factors. The Milliman Care Guidelines have indicated that clinical indications for admission to inpatient care for those individuals who are suspected of having a transient ischemic attack include patients who are hemodynamically unstable, when focal neurologic signs recur, when there are findings on brain imaging that require inpatient care, when the patient has altered mental status, has cardiac arrhythmias of immediate concern, when there is clinically significant cardiac or vascular disorders identified that require inpatient care such as severe valvular disease, atrial myxoma, or arterial dissection, when the patient had 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. If prolonged cardiac telemetry monitoring is needed, has suspected vasculitis, or is pregnant, inpatient care is recommended. 

 In the case of this individual, the information submitted for the review did not support that he met the criteria for inpatient care.  The patient could have had his assessments, diagnostic testing, and treatment safely rendered on an observational or an outpatient basis. Records do not support that there were any significant abnormalities noted on physical examination or on diagnostic testing to justify inpatient level of treatment. He was recommended for aspirin, which would be the recommended course of care with appropriate follow-ups with his primary treating physician and/or cardiologist. Therefore, after review of the provided information, it was determined that the prior determination is upheld.  The full hospital admission was not medically necessary.

The healthcare plan acted reasonably and was signed medical judgment and in the best interest of the patient.

The insurer's denial of coverage for the full hospital admission is upheld. Medical Necessity is not substantiated.