Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope

Treatment: Inpatient admission 

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

This patient is a male with a past medical history of gastritis and frequent syncopal episodes who presents for evaluation of a syncopal episode and myalgia's. The patient is very sleepy during the interview and minimally cooperative. He reports that he has been feeling bad for months and reports myalgia's for one month and a nonproductive cough for the past week. He has had a significant decrease in his oral intake and reports weight loss of 30-40 pounds over the past several weeks. He reports chest pain that he describes as "all over", squeezing and 10/10 in intensity, starts and stops at random and radiates to his abdomen. He falls asleep frequently during the interview and when awoken he simply continues talking as though he did not stop previously. He says that these are the same episodes that happen frequently at home. He reports that his sister witnessed the event today when he lost consciousness for 2-3 minutes. He thinks he hit the back of his head" he states that he has never had a workup for these episodes and that he does not have a primary care physician. His vital signs are temperature 36.8 C, Blood Pressure 150/90, pulse 71, respirations 18 and oxygen saturation 100%. It was thought that syncope might be due to hypovolemia due to persistent vomiting and decreased oral intake. A note written on the day after presentation stated that the patient insisted on leaving AMA. He would not allow the staff to do vital signs and he refused to wait for the medical doctor to assess his condition.

Syncope may be classified as reflex, orthostatic, hypotensive, and cardiac. The commonest cause, irrespective of age, sex, or comorbidity, is vasovagal (1). Orthostatic integrity is largely maintained by the interaction between the skeletal muscle pump, neurovascular compensation, neurohumoral effects, and cerebral blood flow regulation. Subclinical levels of inadequate blood pressure regulation in response to orthostasis have been linked to increased depression and anxiety (2). A recent widely accepted guide to the treatment of syncope was published in 2009 as a State-of-the-Art paper (3) In general, hospital admission is prudent if the suspected underlying problem is associated with high risk of early mortality or injury, the proposed treatment requires in-hospital care, or the affected individual is unable to care for himself or herself. 

This patient presented to the hospital with a history of multiple syncopal episodes over an extended period of time. He had gastritis and claims that he had lost more than 30 pounds in a short period of time because of this. His history was complicated by his constantly falling asleep during the interview and his ultimately signing out against medical advice, which may have been related to his positive urine toxicology screen. The literature that I have cited lists many variables which indicate the patient is at increased risk and these do not appear to be present in this patient. Other than the prolongation of his QTc none of these other variables were present. The prolongation of the QTc was most likely related to his low potassium which was due to his extensive vomiting. 

He did not have any variables that are mentioned in the literature that I have cited to indicate that he was at increased risk. Based on this literature I do not think that the inpatient admission was medically necessary. Therefore, the denial of coverage for this inpatient admission should be upheld. 

The health plan acted reasonably and with sound medical judgment and in the best interest of the patient.

Based on the above, the medical necessity for the inpatient admission is not substantiated. The insurer's denial is upheld.