Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient is a female with a significant past medical history of breast cancer status post lumpectomy who presented to the emergency department (ED) after experiencing two syncopal episodes, accompanied by ankle pain resulting from a fall. She reported developing abdominal cramps, nausea, vomiting, and watery diarrhea later in the evening following a dinner outing with her husband.
During transit home, the patient experienced a syncopal episode, leading to a fall and twisting of her ankle. Emergency Medical Services reported a blood pressure of 70/60 on site, which improved with fluid administration. Upon ED arrival, her vital signs were stable. Laboratory results revealed leukocytosis and a low magnesium and phosphorus levels. An ankle x-ray showed a nondisplaced fracture, while a chest x-ray exhibited no significant findings. A right upper quadrant ultrasound ruled out cholecystitis, and the abdominal-pelvic computed tomography (CT) scan displayed no abnormalities. Orthopedics placed an air cast on her ankle, and the patient received a 2-liter (L) fluid bolus with electrolyte repletion in the ED.
The patient was initially planned for discharge from the ED. The patient continued to have low blood pressure and the hypotension prompted further investigation, revealing a history of low blood pressure and vasovagal episodes. 
Upon admission to telemetry, the patient maintained hemodynamic stability, with no cardiac arrhythmias observed during hospitalization. An echocardiogram showed a normal ejection fraction and no valvular pathology. Physical therapy confirmed the patient's ability to ambulate with crutches, and outpatient orthopedic surgery follow-up was recommended.
The patient was ultimately deemed medically stable and was discharged from the hospital. At issue is the medical necessity of an inpatient stay.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
There were no clear indications for admission at the acute inpatient level of care since there were no signs of hemodynamic instability or severe or persistent altered mental status. There was no mention that imaging studies revealed evidence of an acute stroke, brain mass, or hydrocephalus.
There was no indication that the syncopal episode was related to pulmonary embolism, arterial dissection, acute congestive heart failure (CHF) exacerbation, acute blood loss anemia, or acute coronary syndrome.
There were no indications for immediate electrophysiological study or other interventions such as automatic implantable cardioverter defibrillator (AICD) placement.
Based on the telemetry monitoring there was no evidence that the patient had a high degree of atrioventricular block, bradycardia with sinus pauses, or bursts of supraventricular tachycardia.
There was no evidence that the patient was severely dehydrated. The review of the medical records revealed that the patient remained in stable clinical condition during the entire hospital stay, and did not require any treatment or testing that would justify admission at the acute inpatient level of care.