Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/ Neuromuscular Disorder/ Other/ Syncope
Treatment: Inpatient Hospital/ Inpatient admission
 The health plan has denied the inpatient admission as not medically necessary. The health plan's determination is upheld. 

The patient is a male with no significant medical history who presented to the emergency department with concerns for syncope. His initial vital signs revealed a temperature of 97.4 degrees Fahrenheit, a heart rate (HR) of 55 beats per minute (bpm), a blood pressure (BP) of 103/55 millimeters of mercury (mmHg), a respiratory rate (RR) of 16 breaths per minute, and a peripheral capillary oxygen saturation (SpO2) of 96 percent (%) on room air. Initial examination documented the patient as alert and oriented to person and place, but not oriented to time, without focal neurologic deficits. His electrocardiogram (EKG) revealed sinus bradycardia with a ventricular rate of 56 bpm without ischemia or conduction abnormalities. Initial laboratory testing revealed a white blood cell count (WBC) of 6.5, hemoglobin (Hgb) of 13.8, platelet (Plt) count of 130, blood urea nitrogen (BUN) of 22, creatinine (Cr) of 1.0, blood glucose of 94, potassium (K) level of 5.9 with a repeat of 4.2, and high sensitivity cardiac troponin of 33.2 which decreased to 29.5 on repeat. His chest x-ray (CXR) showed left basal opacities, possibly pneumonia or atelectasis. The computed tomography (CT) scan of his head did not reveal an acute intracranial bleed, but did note mild symmetric dilation of the lateral ventricle, third ventricle, and temporal horn suggestive of mild communicating hydrocephalus. The patient was placed in the hospital thereafter with an impression of syncope. The treatment plan included telemetry, echocardiography, magnetic resonance imaging (MRI) of the brain, and an electroencephalogram (EEG). He had no new issues, and his echocardiogram was relatively unremarkable. His EEG revealed bilateral slowing which was worse on the left and occipital sharp waves. He continued to have no new issues. Neurology was consulted and ruled out non-pressure hydrocephalus. Neurology recommendations were to initiate oral Keppra and follow-up in an outpatient setting. The patient was discharged thereafter.
At issue is the medical necessity of the inpatient hospital admission.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of inpatient admission was not medically necessary. 
Runser et al. published guidelines in regard to the evaluation and management of syncope. These guidelines suggest that hospital admission be considered if the patient has a clinical history suggestive of arrhythmic syncope, severe anemia, electrolyte abnormalities, electrocardiograph history suggestive of arrhythmic syncope, family history of sudden death, hypotension, severe structural heart disease, congestive heart failure, or coronary artery disease.[1]
This patient had no significant medical history.
Moreover, clinical indications for admission to inpatient care were not met. The patient did not have hemodynamic instability, altered mental status, pacemaker or automatic implantable cardioverter defibrillator (AICD) malfunction, or severe or persistent dehydration. The patient also did not have a cardiac disease or finding that indicated necessity of immediate intervention, as indicated by outflow tract obstruction, ventricular dysfunction, cardiomyopathy, significant valvular disease, subclavian steal syndrome, aortic dissection, cardiac tamponade, acute myocardial ischemia, sustained or symptomatic ventricular tachycardia, symptomatic conduction systemic disease, bradycardia or sinus pauses, atrial fibrillation with rapid ventricular response with outpatient medication titration inappropriate, or supraventricular tachycardia with outpatient medication titration inappropriate.[2]