Diagnosis: hypertension and syncope
Treatment: inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld.

This is an adult male with a medical history of hypertension, chronic kidney disease, and diabetes.

The patient was admitted with hypertensive emergency and syncope. The patient was aphasic with left facial droop and syncope. It was noted the patient returned to baseline upon arrival to the Emergency Department (ED). It was noted the patient has elevated blood pressure and missed his morning medications. The diagnosis was syncope versus seizure. Exam with no neurologic abnormalities was noted. The patient had no signs of stroke, seizure or persistent altered mental status that was different than baseline.

Patient had elevated blood pressure with normal heart rate, intravenous fluids (IV) and home Blood Pressure medication (morning medication not taken at home) was given. Computerized tomography (CT) of the head indicated no acute bleed. Upon medical evaluation (neurological), the patient had no focal neurologic deficits, facial droop, fluctuating mental status, or altered mental status from baseline that would require inpatient admission.

Per the MCG (Milliman Care Guidelines) Hypertension M-197 Guidelines, Clinical Indications for Admission to Inpatient Care is supported when there is a Hypertensive emergency, Hypertensive encephalopathy, Cerebral infarction, Intracranial hemorrhage, Myocardial ischemia or infarction, Heart failure, Aortic dissection, Increased creatinine (new) from baseline, Papilledema, Retinal hemorrhage, Microangiopathic hemolytic anemia or Seizure.

The medical records provided for review support that services could have been rendered in observation unit. There was no medical necessity documented to support the inpatient level of care.

"Sudden neurologic dysfunction caused by focal brain ischemia with imaging evidence of acute infarction defines acute ischemic stroke (AIS), while an ischemic episode with neurologic deficits but without acute infarction defines transient ischemic attack (TIA)". (Mendelson, S. J., & Prabhakaran, S.).

Per Majidi, S., et al., "Routine hospitalization of all patients with TIA (transient ischemic attack) 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 (transient ischemic attack); 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.