Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems/Other/Transient Ischemic Attack.
Treatment: Inpatient Hospital.
The health plan denied the requested inpatient hospital stay. The health plan's determination is upheld.

This is a case of a female admitted with a diagnosis of syncope and right-sided weakness thought to be secondary to a migraine, as there was no diagnosis of a transient ischemic attack. The patient presented with a chief complaint of dizziness and syncope. The patient was at work behind the cash register, and she became dizzy with the room spinning; she sat on the counter and then got up to walk from behind the counter and then passed out and fell on the floor. Vital signs demonstrated no fever, a pulse of 70 beats per minute (bpm), a respiratory rate of 18/minute, a blood pressure of 118/70 millimeters of mercury (mmHg) and an oxygen saturation of 98% on room air. A physical exam showed no distress or altered mental status. Labs showed a creatinine of 0.90 with a glucose of 91 and a hemoglobin of 13. A computed tomography (CT) of the head showed no acute hemorrhage or mass effect. A CT angiogram of the carotids and the circle of Willis was unremarkable. A magnetic resonance imaging (MRI) of the brain was performed and was within normal limits. During the hospital stay the patient clinically improved but had a remaining minimal headache. She was then discharged.
At issue is the medical necessity of the inpatient stay.

The health plan's determination of medical necessity is upheld, in whole.

No, the medical necessity of the admission has not been established.
According to Up-to-date, 2020:
"Patient Disposition: Patients with obvious cardiac or neurologic causes of syncope, as well as those with concerning symptoms or signs, should be investigated thoroughly in the Emergency Department (ED) and likely admitted for further in-hospital testing or treatment. To some degree, clinician judgment determines which symptoms or signs are "concerning," but such findings may include:
-	Syncope accompanied by chest pain or shortness of breath.
-	Exertional syncope.
-	Abnormal vital signs.
-	Abnormal findings on cardiac, pulmonary, or neurologic examination.
For well-appearing asymptomatic patients with an unclear cause, clinicians should determine the risk for adverse outcome. Clinicians determine risk on the basis of patient history, examination, and electrocardiogram (ECG) findings, and evidence-based guidelines. The presence of any of the following features determines high risk. 
-	Abnormal ECG.
-	History of structural heart disease or clinical findings suggestive of heart failure.
-	Persistently low blood pressure (systolic < 90 mmHg).
-	Shortness of breath with event or during evaluation.
-	Elevated troponin or BNP (brain natriuretic peptide)(if obtained).
-	Hematocrit < 30 (if obtained).
-	Older age and associated comorbidities.
-	Family history of sudden cardiac death."
According to the documentation submitted, the patient did not have syncope accompanied by chest pain or shortness of breath, exertional syncope, abnormal vital signs, or abnormal findings on cardiac or pulmonary exam. The patient had some mild right-sided weakness, but this was thought to be due to a migraine, as all the imaging studies were negative. There was no abnormal electrocardiogram (ECG), history of structural heart disease, hypotension, elevated troponin, anemia, advanced age, or family history of sudden cardiac death.
Although the patient had needs best addressed in the hospital setting, the monitoring, diagnostic workup, and therapeutic interventions prescribed could have been safely administered at an alternate level of care. Therefore, the medical necessity of the admission has not been established.