Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope

Treatment: Inpatient admission

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

This patient is a female with a past medical history of depression, schizophrenia, osteoporosis and dyslipidemia who was transferred from a psychiatric floor to telemetry after experiencing a syncopal episode while on the psychiatric floor. The patient claims that she was medicated with psychiatric medications since admission to the psychiatric floor the previous day. Today, she felt dizzy while standing in the nursing station and the psychiatric staff put her in a chair. The psychiatric floor staff says that she lost consciousness but the patient says that she was aware of her surroundings but was too weak to respond. A code was called and at that time her BP was 81/47 and her heart rate was 81. Her fasting blood sugar was 170. There was no reported seizure like activity. There was no confusion noted after the event and the patient was noted to be alert and oriented X3. The patient's history is significant for weight loss of 6 pounds over four months. She says that she has not been eating well which is likely secondary to her depressed mood. She claims that she had an episode of watery diarrhea and suspected that the psychiatric medications may be the cause. She was immediately transferred to a telemetry unit where she received a fluid bolus followed by maintenance normal saline at 120 ML/hour.

A CT of the head/brain without contrast was done. The impression was chronic in volitional and white matter changes. No acute intracranial process. Her physicians listed her working diagnosis as syncope likely due to hypotension with dehydration. The plan was to admit the patient to telemetry. She was seen by a cardiology consultant. Echo was done showed an ejection fraction of 55-60% with trace mitral regurgitation and tricuspid rehabilitation. At this time, she was thought to be medically clear for transfer to the psychiatric floor.

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)

Syncope can be caused by serious occult arrhythmias not evident during initial emergency department (ED) evaluation. Investigators sought to develop a risk tool for predicting 30-day arrhythmia or death after ED disposition. They conducted a multicenter prospective cohort study at six tertiary care EDs and included adults (16 years or older) with syncope. These investigators concluded that the Canadian Syncope Arrhythmia Risk Score can improve patient safety by identification of those at risk for arrhythmias and aid in acute management decisions. Once validated, the score can identify low-risk patients who will require no further investigations.(6)

Careful review of this record indicates that the patient did not actually have an episode of syncope, but an episode of presyncope or near syncope. The patient clearly stated that she did not lose consciousness but was too weak to answer the staff that came to assist her. The record also indicates that the patient was hypovolemic due to episodes of watery diarrhea, which is an adequate explanation for the initial low blood pressure. After a fluid bolus, the patient rapidly improved. No orthostatic changes were noted on her examination.

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