Diagnosis: Evaluation for transient ischemic attack.
Treatment: Inpatient hospital admission.
The insurer denied coverage for the inpatient hospital admission.
The denial is overturned.

This is a female patient with a medical history of asthma and diabetes mellitus who was brought in by ambulance to Emergency Department (ED) after experiencing syncope while at work. The patient reported having diarrhea for the prior 2 days after starting new medications, Metformin and Enalapril and experienced left sided weakness and numbness the prior night. She was at work on day of arrival, talking to a coworker, and then she woke up on the floor. Physical examination was remarkable for left upper weakness and paresthesia. Chest x-ray showed decreased lung expansion with mild to moderate congestive changes. Computed tomography (CT) of the head was negative. The patient received, Aspirin oral and Albuterol inhaler and blood pressure medication was held for permissive hypertension. The patient was admitted for further evaluation and management of left sided weakness possibly secondary to transient ischemic attack (TIA)/ stroke and syncope possible due to dehydration. The patient was treated further with intravenous (IV) fluids and continued to receive bronchodilators as needed.

This patient was admitted to evaluate for a TIA. She had persistent left-sided weakness/numbness. This patient had an ABCD2 score of 6 (elevated blood pressure of 170 at presentation, unilateral weakness, diabetes, symptoms lasting over 50 minutes).

The ABCD2 score is a validated, seven-point, risk-stratification tool to identify patients at high risk of stroke following a TIA.1

Patients with scores >=5 such as this patient are at high risk of stroke in the period following a TIA, and may potentially require urgent intervention as inpatients, making inpatient admission appropriate.

The admission was medically necessary to evaluate this possible TIA and minimize her risk of subsequent stroke.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital admission is overturned. The medical necessity is substantiated.