Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld

This is an adult patient who presented to the emergency department complaining of syncope.  The patient had a history of diabetes, hypertension, chronic obstructive pulmonary disease (COPD), emphysema, pulmonary nodules, and depression. The patient reported fainting at home that morning. The patient denied chest pain, headache, or shortness of breath and had no palpitations before the episode. The patient was previously admitted for syncope with normal stress tests and normal echocardiogram. The patient was a current every-day smoker with neurological assessment positive for dizziness, syncope, and lightheadedness. The vital signs were stable. The patient had a fourth syncopal episode and was subsequently admitted for further work-up.  

Admission diagnoses included syncope and collapse along with syncope, unspecified syncope type. At the time of admission, the patient's condition was described as poor. The chest X-ray showed no evidence of acute chest disease. A computerized tomography (CT) of the head without contrast showed no acute intracranial pathology. A transthoracic echocardiogram (TTE) noted systolic function was low normal with an ejection fraction of 50-55%. There was grade 1 (mild) diastolic dysfunction, with the right ventricular cavity mildly dilated. Systolic function was normal, there was a trivial circumferential pericardial effusion anterior and posterior to the heart with normal mitral valve structure. There was trace regurgitation of the aortic valve, probably tricuspid, with normal aortic valve opening. There was trace regurgitation of the tricuspid valve with the right ventricular systolic pressure normal.  

According to Milliman Care Guidelines, the patient did not meet the criteria for admission to inpatient care. The patient was not found to be hemodynamically unstable, nor did the patient have altered mental status that was severe or persistent. The patient was not found to have cardiac disease or findings that indicated the need of immediate intervention. The patient did not have a history of pacemaker or Automatic Implantable Cardioverter Defibrillator malfunction, there was no inheritable cardiovascular condition predisposing the patient to arrhythmias diagnosed or suspected, no indication of dehydration, and no evidence of injury caused by syncope requiring hospitalization. When the patient presented to the emergency department, the vital signs were stable, and the patient was not at imminent risk of cardiovascular failure. The work-up, monitoring, and treatment could have been safely and effectively conducted on an observational or outpatient basis with follow-up with the patient's primary care physician and/or cardiologist. The evidence did not support the need for inpatient admission.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient hospital admission is not substantiated.