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 presented to the hospital.  There was a history of hypertension, seizure, right internal jugular deep venous thrombosis, not on anticoagulation, and meningioma status post-craniotomy.  The patient complained of numbness sensation in the right upper and lower extremities that started the day prior.  This was resolved completely in the emergency department.  The patient denied any weakness, vision changes, vertigo, or headache.  Vital signs noted temperature of 98.1 degrees F (Fahrenheit), pulse of 120, respirations of 20, and blood pressure of 157/100.  The patient's pulse oximetry was 97% on room air.  Physical exam noted normal range of motion.  There was a plan to rule out transient ischemic attack.  Computed tomography (CT) of the head noted no acute intracranial hemorrhage or acute territorial infarction.  There was a prominent area of encephalomalacia posterior left parietal region at the vertex that was likely related to sequela of prior ischemic event or could be related to prior traumatic brain injury.  The patient was given aspirin, clopidogrel, and atorvastatin.  Frequent neurological checks were recommended.  Laboratory results on the patient noted white blood cell count of 9.0, red blood cell count of 5.17, hemoglobin of 14.0, and hematocrit of 42.1.  The patient's prothrombin time (PT) was 13.1 with international normalized ratio (INR) of 0.98 and partial thromboplastin time (PTT) of 24.2.  The patient's Blood urea nitrogen (BUN) was elevated at 26.  The patient was evaluated by neurology.  Magnetic resonance imaging (MRI) showed left parietal encephalomalacia status post meningioma resection.  Electroencephalogram (EEG) was reported as normal awake study.

Per the cited references, admission for transient ischemic attack is indicated when there is hemodynamic instability such as with tachycardia or hypotension that persist despite appropriate treatment, when focal neurological signs recur, when there are findings on brain imaging that require inpatient care, when there is altered mental status, when there is cardiac arrhythmia of immediate concern, when there is a clinically significant cardiac or vascular disorder identified, when there is severe hypertension with systolic blood pressure greater than 180 or diastolic blood pressure greater than 120, when there is prolonged cardiac telemetry monitoring that is needed beyond observation care timeframes, when there is suspected vasculitis, or when parenteral anticoagulation is needed.  

In this case, the patient presented to the hospital with complaints of numbness sensation in the right upper and lower extremities.  The symptoms resolved in the emergency department.  Magnetic resonance imaging showed left parietal encephalomalacia status post meningioma resection.  Electroencephalogram was reported as normal awake study.  Based on the provided documentation, admission level of care was not supported by the clinical documentation.  There was no hemodynamic instability, focal neurological signs that had recurred, imaging that required inpatient care, altered mental status, cardiac arrhythmia, cardiac vascular disorder, severe hypertension, vasculitis, need for parenteral anticoagulation, or need for prolonged cardiac telemetry monitoring beyond observation care timeframes.  The patient's care could have been completed at a lower level.  

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.