Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Migraine

Treatment: Inpatient admission

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

This is an adult female who presented with left arm heaviness, left hip pain, left-sided numbness, left eye blurry vision, left leg heaviness and gait instability. The patient was seen for a stroke alert and was treated for migraine. The electroencephalogram (EEG) was negative, and the magnetic resonance imaging (MRI) had no changes. The patient's neurological exam was negative, and the patient was hemodynamically stable. The request is for Inpatient admission, which is under review.

The patient had a normal MRI, EEG and physical exam. Observation level of care was appropriate for this patient.

Per Taylor, R. S., Opara, N. U., & Burg, J., "There were 983 patients included in the study. The patients on transient ischemic attack (TIA) prophylactic medications prior to coming to the emergency department (ED) made up (60.7% [percent]), and (51.2% [percent]) in this group required additional medications during hospital admission. The remaining 162 (39.3% [percent]), p=0.001 patients, were not on TIA prophylactic medications prior to presenting in the ED. The patients who required additional medications while in the ED were significantly older (mean +/-SD [standard deviation], 68.6 +/-14.0 years versus 62.18 +/- 17.4 years, p=0.001). Following a multivariate analysis, age greater than 60 (CI: 3.52-3.91, p=0.001) and results of the head computed tomography (CT) /MRI investigations for any signs of neurological damage, were all found to be independent predictors of longer hospital stay and treatment outcomes. There were no significant differences in the treatment outcome for patients with TIA based on longer hospital stays and extra medication administration in the ED.

Conclusion: In our study, we observed that approximately, 75% (percent) of the patients who were on TIA prophylactic medications prior to presenting in the ED with symptoms of TIA were admitted to the hospital for further monitoring, compared to other group of patients who were not on TIA medications. We did also note that there were no differences in mortality outcome between patients treated and discharged from the ED, versus patients admitted to the hospital for additional treatment."

Per Majidi, S., et al., "Routine hospitalization of all patients with TIA or minor ischemic stroke may not positively affect short-term clinical outcome."

Per Homoya, B. J., et al., "Many factors contributed to decisions regarding admitting a patient with TIA; however, clinicians' uncertainty appeared to be a key driver. Further quality improvement interventions for TIA care should focus on facility adoption of TIA protocols to address uncertainty in TIA admission decision-making and to standardize timely evaluation of TIA patients and delivery of secondary prevention strategies."                                                         

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

The medical necessity for the inpatient admission is not substantiated.