Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Possible syncopal episode
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female who was transported to the emergency department via Emergency Medical Services (EMS) for evaluation of altered mental status, "dizziness" and a possible fall versus syncope. The history was limited by the patient's underlying dementia. Her baseline mental status was not known. Her medical history was remarkable for traumatic brain injury, coronary artery disease, permanent pacemaker implantation, and hyperlipidemia.
Her blood pressure was 170/94 millimeters of mercury (mmHg) with a heart rate of 64 beats/minute. Her respiratory rate was 20/minute with a room air oxygen saturation of 98%. The patient was oriented to person but not to time or place. There was a superficial abrasion on her left knee. An electrocardiogram showed a paced rhythm. Head computed tomography (CT) scan and chest x-ray showed no acute pathology. Her cardiac biomarkers were normal. She was admitted to the hospital for evaluation of altered mental status and possible syncope. She was treated with intravenous fluid. She was oriented to person and place. She was seen by a neurologist who found no focal neurologic deficits. An electroencephalogram (EEG) was recommended as was psychiatry consult for possible anxiety. The patient's pacemaker was interrogated and was found to be functioning normally; no arrhythmias were stored in the log. The patient had no complaints. She was fully oriented. She was seen by a psychiatrist who recommended Buspar and hydroxyzine for anxiety. The patient was discharged. Medical necessity for inpatient admission is an issue.

The health plan's determination is upheld.

Based on the documentation provided an inpatient admission was not medically necessary. This patient was admitted to the hospital after a possible syncopal episode. She was hemodynamically stable without evidence of acute ischemia or decompensated heart failure. Interrogation of her permanent pacemaker showed normal device function and no arrhythmias were stored in the device's log. The Head CT scan was said to be normal. The literature does not adequately describe which patients with syncope will benefit from inpatient hospital admission or observation nor has it demonstrated the value of admission in preventing future adverse outcomes. However, certain features have been identified as signifying high risk. These include exertional syncope, known structural heart disease, age greater than (>) 60 years, and a family history of sudden cardiac death. This patient had none of these features. Per the 2017 American College of Cardiology (ACC)/American Heart Association (AHA)/Heart Rhythm Society (HRS) Guideline for the Evaluation and Management of Patients with Syncope, inpatient admission is recommended for patients presenting with syncope who have a serious medical condition potentially relevant to the cause of syncope identified during the initial evaluation. This patient had no such condition identified. Thus, based on the information provided about this patient, an inpatient admission was not medically necessary for the evaluation of her possible syncope. The patient could have been appropriately managed at a lower level of care status.
Upon admission, the patient was oriented only to the person. However, she had a history of dementia, and her baseline mental status was not known. Her neurologic exam was nonfocal, there were no serious metabolic derangements, and her head CT scan showed no acute pathology. The documentation provided does not indicate that an evaluation of this patient's mental status warranted an inpatient admission.