Transient Ischemic Attack denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for external mobile cardiovascular telemetry monitor services. Continuous cardiac monitoring is a well-established component of the diagnostic workup for suspected ischemic stroke or transient neurologic deficits. Leading expert guidelines recommend at least 24 hours of continuous cardiac monitoring for all patients with suspected acute ischemic stroke or transient ischemic attack, with extended outpatient monitoring when an initial evaluation is unrevealing. The results from a recent meta-analysis reinforce these recommendations. In this case, the patient presented with a cryptogenic transient ischemic attack and acute right-sided sensory-motor deficits, and magnetic resonance imaging of the brain was unremarkable.

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for brain magnetic resonance imaging (MRI) (CPT 70553), and/or head magnetic resonance angiography (MRA) (CPT 70546), and/or neck MRA (CPT 70549). Diplopia is a common symptom identified in ophthalmological and neurological patients with multiple underlying causes. The onset of diplopia is most often sudden, but it can also be gradual, determined by trauma, or spontaneous. While the acute onset is more suggestive of a vascular event but is not specific, the gradual progression or diplopia that has changed the pattern is more indicative of a compressive lesion (Iliescu, et al.). In the diagnosis and management of transient ischemic attack and stroke, imaging of the brain and intracranial and extracranial blood vessels is an important part of the diagnostic assessment.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) services including physical therapy and occupational therapy services provided for treatment of the enrollee’s transient ischemic attack (TIA), epilepsy, and pressure ulcers. Findings: The physician reviewer found that based on the medical records provided for review, the SNF services including physical therapy and occupational therapy services provided were not and are not medically necessary for treatment of this patient’s medical condition. Patients require SNF services or skilled rehabilitation services when they are needed on a daily basis and the daily skilled services can be provided only on an inpatient basis in a SNF. The documentation does not reveal that this patient requires SNF services.

The patient is a 64-year-old female who requested authorization for Provigil. She has had transient ischemic attacks (TIAs) occurring over the past two years, fatigue and excessive daytime sleepiness. Her provider has diagnosed circadian rhythm disorder, as the patient is unable to remain awake during the day. A one-month trial of Provigil appeared to be effective in relieving her excessive daytime sleepiness and fatigue. The Provigil was used in conjunction with the sleep aid medication, Ambien. The patient’s daughter stated the medication improved the patient’s quality of life. Based on the one-month trial, the patient’s provider has prescribed Provigil 200mg day.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving transient ischemic attack, then check the rights and deadlines that apply to your plan.