Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld.

This case involves an adult patient who presented to the emergency room complaining of a syncopal episode. The patient reportedly lost consciousness and was found by family. The patient reported chest pain as a stabbing/pressure-like quality and claimed to have dizziness and emesis episodes for 3 days prior to the syncope. The patient claimed to have a past medical history of scoliosis and was prescribed 30 milligrams (mg) OxyContin to be taken every 6 hours. In addition to seizures, the patient had a history of seizures, anemia, anxiety, asthma, depression, blood clots, preeclampsia, and thyroid disease. The patient complained of dizziness on arrival, with vital signs showing blood pressure 192/87 and a pulse of 92 with a temperature of 100.1.  On reassessment several hours later, vital signs were stable other than a slightly elevated temperature at 100.1. A Computed Tomography (CT) of the head was negative. Laboratory values showed a low red blood cell count at 3.71, hemoglobin low at 8.8, hematocrit low at 27.6, mean corpuscular volume at 74.3, mean corpuscular hemoglobin at 31.8, elevated red cell distribution at 18.1, low mean platelet volume at 7.0, and platelets at 470. A comprehensive metabolic panel showed low sodium at 132, low calcium at 8.1, low total protein at 5.8, and low albumin at 3.2. The patient was negative for Coronavirus, and coagulation studies were normal. The patient had tenderness to the abdominal region in the epigastric area. The patient also had dysphagia. The patient claimed to have been prescribed Klonopin and oxycodone 30 mg 4 times a day for chronic back pain and scoliosis but claimed to never have been put on seizure medications. Hematology reports indicated microcytic anemia and thrombocytosis. Chest x-rays of the lungs were clear with normal cardiomediastinal silhouette. An electrocardiogram indicated sinus tachycardia. The patient was loaded with Keppra 2 grams per neurology recommendations and Keppra 500 mg twice a day. Gastroenterology was consulted and endorsed the patient had no active bleeding. Neurology was consulted given the patient's remote history of a seizure and recommended Lamictal 50 mg twice a day with no further work-up. The patient was subsequently discharged. 

According to the Milliman Care Guidelines, the patient was not hemodynamically unstable, was not status epilepticus, and did not have a brain disorder that required monitoring or intervention available only at inpatient level of care. Furthermore, there is no indication of an etiology that requires monitoring or intervention available only at inpatient level of care or that the symptoms persisted despite observation care. The patient did not have altered mental status that was severe or persistent, there was no new focal neurologic deficit, no metabolic disorder that persisted despite observation care and the patient had no recurrent seizures during the emergency department or observation care. Lastly, the records did not claim that the outpatient antiepileptic regimen could not be established nor was there a need for monitoring of cerebral bleeding, hydrocephalus, or vasospasm and no monitoring needed for increased intracranial pressure or cerebral edema. The laboratory results showed some abnormalities, but imaging studies were negative for acute pulmonary or cranial abnormalities. The evidence did not support that the patient's condition could not be safely and effectively treated and monitored on an observational or outpatient basis. 

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 admission is not substantiated.