Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Transient Ischemic Attack

Treatment: Inpatient Admission

The insurer denied coverage for inpatient admission.

The denial is upheld.
 
The patient is an adult female who presented to the emergency department with complaints of slurred speech, facial paresthesia, right facial droop, and elevated blood pressure (BP). The patient has a prior history of a cerebrovascular accident (CVA), Lupus, Type 1 Diabetes Mellitus (T1DM), Antiphospholipid Syndrome, Scleroderma, Hypothyroidism, and obesity. Upon the patient's arrival, a stroke code was called, and aspirin (ASA) was administered. The patient's labs, troponin levels, computed tomography (CT) neuro perfusion, and chest X-ray were unremarkable. The CT carotid was negative, and the electrocardiogram (EKG) showed normal sinus rhythm (NSR) at 64 beats per minute (BPM). A neurology consultation was obtained, and the patient was admitted to the telemetry stroke unit. The patient was diagnosed with a transient ischemic attack (TIA) and elevated troponin levels, while a CVA was ruled out. The patient's care plan included permissive hypertension and neurological checks every 2 hours (Q2H), troponin monitoring, aspirin administration, prehospital medications, glucose monitoring, and a carbohydrate-controlled diet. Additionally, the plan involved the use of sequential compression devices (SCDs), labs, an echocardiogram (ECHO), and magnetic resonance imaging (MRI) of the brain. The Brain MRI revealed a chronic infarct in the inferior left precentral gyrus and stable chronic bilateral cerebellar lacunar infarcts. The ECHO revealed an ejection fraction (EF) of 61%, mild mitral regurgitation, and trivial tricuspid regurgitation. The patient reported worsening complaints and neurological facial asymmetry. A repeat CT noted a left frontal suprasylvian wedge-shaped hypodensity with volume loss compatible with an old gliotic middle cerebral artery (MCA) ischemic event. The patient underwent a hematology consultation and a physical therapy (PT) evaluation. The patient refused the recommended treatment and left the hospital against medical advice (AMA).  

Based on the clinical documentation, it would have been medically appropriate to provide observational care to complete diagnostic testing before considering a full admission.

Milliman Care Guidelines 27th Edition using the guideline of Transient Ischemic Attack (TIA) ORG: M-360 (ISC) Care Planning - Inpatient Admission and Alternatives
Clinical Indications for Admission to Inpatient Care:

Admission is indicated for one or more of the following:
Hemodynamic instability
Focal neurologic signs that 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 ECHO, imaging) that requires inpatient care (e.g., severe valvular disease, atrial myxoma, arterial dissection)
Severe hypertension (systolic blood pressure (SBP) greater than 180 or diastolic blood pressure (DBP) greater than 120, or greater than the 95th percentile for age, gender, and height plus 30 in pediatric patients)
Prolonged cardiac telemetry monitoring needed (e.g., beyond observation care time frame)
Suspected vasculitis
Pregnancy

In this case, based on the clinical presentation, observational care would have been medically appropriate. 

Based on the above, the insurer's denial must be upheld. The health care plan acted reasonably, with sound medical judgment, and in the patient's best interest. 

The medical necessity for the full hospital admission is not substantiated.