Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is a school-aged female child with medical history significant for autism and constipation that presented to the emergency department after she experienced three episodes of syncope. The first episode happened the night prior while she was on the toilet straining to pass a bowel movement. She fell over; the episode lasted about 20 seconds, and blood pressure was 83/51. The second episode happened while she was brushing her teeth. She lost tone but did not fall to the ground because her mother caught her. The third episode happened fifteen minutes later. Her mother took her to the emergency room because she was concerned that because her child would put things in her mouth that she had taken diabetes/thyroid/hypertension medication. She was otherwise eating and drinking well. She had no rashes or fever. 

The patient's vital signs included temperature 36.9, heart rate 118, respiratory rate 24, and blood pressure 92/57. Examination was significant for no distress, clear lungs, benign abdomen, and good perfusion. There was no suspicion for ingestion based on her examination. There was no concern for seizure. She was at her neurologic baseline. Bedside glucose was 83. Laboratory evaluation was significant for mild thrombocytosis (platelets 432 thousand), hyponatremia (sodium 131), and carbon dioxide 20. The patient was treated with a normal saline bolus for mild dehydration. Electrocardiogram (EKG) was remarkable only for tachycardia. Rapid viral screening was negative. She was admitted for Cardiology service for telemetry monitoring. Admission orders included maintenance intravenous fluids, orthostatic blood pressure measurements. She had no 
arrhythmia on telemetry monitoring. She was not orthostatic. Abdominal x-ray revealed mild stool burden within the rectum. Cardiology consultation was sought with recommendation for echocardiogram that was unremarkable. They diagnosed vasovagal syncope with no further cardiac follow-up needed. The patient developed upper respiratory viral symptoms consistent with family ill contacts. Respiratory pathogen panel was negative. Her oral intake improved, and she was deemed stable for discharge on day # (number) 3.

The acute inpatient hospital admission was not medically necessary.

Syncope is a common complaint in the pediatric population. Syncope affects about 15% (percent) of children under 18 years of age. Most times, pediatric syncope is a benign occurrence. Etiology may be related to vasovagal dysfunction, hypertrophic cardiomyopathy, or seizure. Additional cardiac causes include arrhythmia and long QT (interval on EKG when the heart's electrical system recharges between heartbeats) syndrome. There are also a number of psychiatric disorders that may result in syncope. Of all the possibilities, vasovagal syncope is the most common cause of syncope. In most cases, medications are not needed; lifestyle modifications may be sufficient. If medications are necessary, options might include hydrocortisone, beta blockers, fludrocortisone, midodrine, or serotonin reuptake inhibitors. 

This female child with history of non-verbal autism experienced three episodes of syncope or near-syncope within 24 hours. Laboratory evaluation and cardiac evaluation were unremarkable. She was admitted for further monitoring and telemetry as well as Cardiology consultation. While it was reasonable to monitor the patient for arrhythmia and/or recurrence of syncope, she was overall hemodynamically stable without significant metabolic abnormality or severe dehydration. 

She did not require acute inpatient hospital admission and could have been safely managed at a lower level of care.