Appeal type: Medical necessity
Decision: Upheld

Diagnosis:Cardiovascular disease-Syncope
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay as not medically necessary
The determination is upheld in whole

The patient has a past medical history significant for hypertension and gout and presented to the emergency department after  a syncopal episode.
The patient woke up at 2 AM and went to get some water. While walking from the kitchen to the living room, patient started to feel dizzy and lightheaded, at which time passed out. The patient reported that while falling hit head on a chair. Reportedly, the patient remained unconscious for several seconds. When the patient woke up there was confusion and disorientation. Patient  got up and started to walk to the kitchen and passed out again for several seconds. At the time of admission, the patient complained of one episode of watery diarrhea. The patient reported decreased oral intake and feeling weak. In addition, the patient noticed cough and myalgias in the last three days that preceded the day of admission. There was no history of syncopal episodes or seizures in the past.
When the patient was seen in the emergency department, patient was afebrile, blood pressure was 151/81, heart rate 110 beats per minute (bpm), respiratory rate 18 breaths per minute, oxygen saturation 97% on room air. Subsequently, the tachycardia improved, and the heart rate went down to 95 bpm. The patient was checked for orthostatic changes. Based on the blood pressure measurements, there was no evidence of orthostatic hypotension. The patient was admitted to the hospital with syncope. The evaluation included an echocardiogram, and a computed tomography (CT) scan of the head. These studies were performed and demonstrated no clinically significant abnormalities. Subsequent testing revealed that the patient was positive for influenza A. However, it was not totally clear when  influenza symptoms started. In the hospital, the patient received additional intravenous fluids. The telemetry monitoring that was performed throughout the hospitalization showed no events. During the hospital stay the patient remained in stable clinical condition except for one syncopal episode, which occurred soon after admission. 

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
In order to determine if the patient required admission at the acute inpatient level of care for the evaluation of the syncopal episode, I referred to the San Francisco Syncope Rule, which is a risk stratification tool. It predicts risk for serious outcomes at 7 days in patients presenting with syncope or near-syncope. Based on the calculations, this patient received one point. This means that the patient did not belong to a low-risk group for serious outcomes. Therefore, this patient definitely required admission to the hospital for further evaluation, especially considering the fact that the patient had at least two syncopal episodes at home and one in the hospital. Having said that, the review of the medical records did not demonstrate evidence of hemodynamic instability, severe or persistent altered mental status, evidence of stroke, pulmonary embolism, arterial dissection, acute congestive heart failure (CHF) exacerbation, or acute blood loss anemia. The admission at a lower level of care was certainly appropriate.
In addition, Milliman Care Guidelines (MCG) Health Inpatient & Surgical Care 23rd Edition criteria for Syncope were reviewed. Based on the criteria, the admission at the acute inpatient level of care is justified in cases of hemodynamic instability, severe or persistent altered mental status, certain conditions that could trigger syncopal episode such as stroke, brain mass, hydrocephalus, pulmonary embolism, arterial dissection, acute CHF exacerbation, acute blood loss anemia. Based on the criteria, the admission at the acute inpatient level of care in patients with syncope is also required in cases of cardiac disease or findings that indicate the necessity of immediate electrophysiological study, surgery, prolonged telemetry monitoring, or when patients present with cardiac ischemia. The review of the medical records revealed that there was no overwhelming evidence that the patient met those criteria.