Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems/Other/TIA Transient Ischemic Attack
Treatment: Inpatient Hospital
The health plan denied the inpatient stay as not medically necessary. 
The health plan's determination is upheld.

The female patient presented to the emergency department with concerns of dizziness, palpitations, and leg weakness. The initial National Institute of Health Stroke Scale (NIHSS) was 4. Initial laboratory testing revealed a white blood cell count (WBC) of 5.4, a hemoglobin of 12.2, platelets of 241, an international normalized ratio (INR) of 0.9, a sodium of 141, a potassium of 3.6, a carbon dioxide (CO2) of 26, a blood urea nitrogen (BUN) of 11, a creatinine of 0.57, a glucose of 96, a calcium of 9.4, and a creatine kinase (CK) of 49. An electrocardiogram (EKG) was relatively unremarkable. A chest radiograph was unremarkable. A computed tomography (CT) of the head did not reveal an acute intracranial pathology. A computed tomography angiography (CTA) of the brain/neck was unremarkable. A magnetic resonance imaging (MRI) of the brain did not reveal an acute intracranial event. A neurology consultation was obtained whom had an impression of symptoms consistent with viral syndrome with psychogenic overlay, possibly panic attack. No indications for a cerebrovascular accident (CVA) were noted. The patient was placed in the hospital thereafter. The treatment plan included telemetry and observation. The patient felt about the same and was discharged.

The health plan's determination of medical necessity is upheld, in whole. Based on the clinical documentation provided, evidence-based literature and standards of care, acute inpatient level of care was not indicated as medically necessary for the entire admission.

An extensive evaluation was performed including an EKG, echocardiogram, CT of the head, CTA of the brain/neck, and an MRI of the brain, which all were essentially unremarkable. Neurology consultation was obtained whom had an impression of a viral syndrome with psychogenic overlay. Following observation care, the patient was discharged. No other issues or complications were documented.

The patient did not have clinical indications for admission to an acute level of care. The patient did not have hemodynamic instability, focal neurologic signs or symptoms that persist or recur, severe or persistent altered mental status, 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), pregnancy, suspected vasculitis, 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 (Xaban) inhibitor (e.g., Rivaroxaban, Apixaban) is present (e.g., severe thrombocytopenia, allergy, creatinine clearance (CrCl) less than 30 mililiters/minute/square meter (mL/min/1.73m2), pregnancy, liver disease with coagulopathy, or mechanical heart valve).[2]