Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems/Other/Orthostatic Hypotension
Treatment: Inpatient Hospital
The health plan denied the inpatient hospital stay as not medically necessary. 
The health plan's determination is upheld.

The patient is a male with a past medical history significant for hypertension, coronary artery disease, status post percutaneous coronary intervention (PCI), hyperlipidemia, diabetic neuropathy, congestive heart failure, and morbid obesity who presented to the hospital after he had a fall.
The patient went to the bathroom and started to feel dizzy. He fell and hit his head but did not lose consciousness. The patient stated that his blood pressure remained low most of the time. The patient stated that his primary care physician had decreased his daily dose of Hydralazine and Imdur. He continued to take Entresto, Coreg, and Spironolactone.

The patient was admitted to the hospital with syncope due to polypharmacy in antihypertensive medications. It was mentioned that the patient had positive signs of orthostatic hypotension and responded to the administration of intravenous fluids. The electrocardiogram (EKG) showed no acute changes, and the computerized axial tomography (CAT) scan of the head was negative. An echocardiogram was ordered to evaluate cardiac function. At the same time, it was noted that the patient had a severely reduced ejection fraction that was 20-25%, and the patient was utilizing a LifeVest. In the hospital, he was seen by a cardiologist.
During the hospital stay, the dosages of the patient's antihypertensive medications were adjusted without any further episodes of hypotension. While in the hospital the patient sustained a mechanical fall due to slipping on the wet floor.
Overall, during the hospital stay, the patient remained in stable clinical condition, therefore was discharged from the hospital with a recommendation to follow up with his cardiologist as an outpatient.
At issue is the medical necessity of the inpatient stay.

I uphold in whole the health plan's determination of medical necessity.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
I did not see clear indications for admission at the acute inpatient level of care since there were no signs of hemodynamic instability after the patient received treatment with intravenous fluids. There was no mention of severe or persistent altered mental status. The imaging studies did not reveal evidence of acute stroke, brain mass, or hydrocephalus. There was no indication that the syncopal episode was related to a 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 intervention such as an automatic implantable cardioverter defibrillator (AICD) placement. The patient already had a functioning LifeVest. Based on the telemetry monitoring, there was no evidence that the patient had a high degree atrioventricular block, bradycardia with sinus pauses, or bursts of supraventricular tachycardia. Furthermore, 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.
There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at an alternate level of care rather than admission to an inpatient level of care. 
Overall, this patient remained in stable clinical condition after he received treatment with intravenous fluids and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.