Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Transient Ischemic attack
Treatment: Hospital admission
The insurer denied coverage for hospital admission
The denial is overturned

Computed tomography (CT) of the head indicated no acute hemorrhage or infarct. Findings were consistent with mild chronic small vessel ischemic disease. A dysphagia screen was done where it was noted that the patient had no facial dissymmetry and passed the swallowing protocol.

MRI on the day after admission indicated an evolving subacute infarct of the right parietal lobe, cerebral atrophy and chronic small vessel ischemic disease.

Progress notes indicated the patient was stable. The provider noted that if 
cardiology and neurology cleared the patient, the patient can be discharged to home and follow up with Primary Care Provider, Neurology and Cardiology.

Progress notes indicated discharge planning pending Carotid Doppler results. Carotid duplex did not show any hemodynamic significant stenosis. Calcified plaques were noted in the right and left internal carotid artery.

Electrophysiology consults indicated that the patient had recurrent strokes in multiple areas, with suspicion of emboli in etiology. An implantable loop recorder (ILR) was recommended.

Progress notes indicated to maintain the patient on telemetry for frequent bradycardia and stat (immediate) electrocardiogram (EKG) showed a question of AV (atrioventricular) block. The plan was to hold Carvedilol and follow up with cardiology. In addition, the progress note indicated to consider Atrial Fibrillation evaluation and Holter monitoring as outpatient per cardiology. A loop recorder was placed prior to discharge.

In the ED (emergency department), the patient was administered Aspirin and Lipitor. Upon serial monitoring, the patient had stroke-like symptoms consistent with failure to achieve symptom control and improvement, further supporting the necessity of acute inpatient care. Once the patient was clinically stabilized and was ruled out for CVA (cerebrovascular accident), the patient met guidelines for a safe discharge.

As per Milliman Care Guidelines (MCG) Health Guidelines Inpatient and Surgical Care 27th Edition: Transient Ischemic attack (TIA) ORG: M-360 (ISC) admission is indicated for 1 or more of the following: hemodynamic instability; focal neurologic signs recur; Findings on brain imaging that requires inpatient care (such as mass); altered mental status; cardiac arrhythmias of immediate concern; Clinically significant cardiac or vascular disorder identified (such as on echocardiogram, imaging) that requires inpatient care (such as severe valvular disease, atrial myxoma, arterial dissection); Severe hypertension (systolic blood pressure greater than 180 or diastolic blood pressure greater than 120, or greater than the 95th percentile for age, gender, and height plus 30 in pediatric patients); Prolonged cardiac telemetry monitoring needed (beyond observation care time frame); Suspected vasculitis; Pregnancy; Parenteral anticoagulation (unfractionated heparin) required (alternative forms of anticoagulation not appropriate or not feasible. 

Based upon these criteria, the patient did require acute inpatient admission. The electrocardiogram (EKG) showed a question of AV block in this patient with extensive cardiac history who was on antithrombolytics.

Furthermore, as noted by Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care 27th edition Arrhythmia: Common complications and conditions CCC:CC-005 (ISC), ongoing inpatient care is indicated for 1 or more of the following: Supraventricular tachycardia (e.g., atrial fibrillation, atrial flutter); Continuous EKG monitoring is required for condition causing arrhythmia (such as severe hyperkalemia, hypokalemia, acid-base disturbance). 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for hospital admission is substantiated.