Appeal type: Medical necessity
Decision: Upheld

Dx: Central Nervous System/Neuromuscular Disorder 
Tx: Inpatient Hospital 

Denied: Inpatient stay 
Denial: UPHELD in whole 

The patient was a female with a past medical history significant for hypertension and childhood asthma who presented to the emergency department after she had an episode of fall and loss of consciousness, which occurred one day before her presentation. 

The patient stated that she was drinking heavily at a party the night before. While on her way home, she fell and lost consciousness and did not remember what happened. According to the history and physical (H&P) note, the bystander did not tell her that she was shaking, there was no report of urinary or bowel incontinence. There was no report of biting the tongue. After the patient regained consciousness, she noticed that her left leg and knee were painful and swollen. 

While seen by the admitting physician the patient denied any chest pain, palpitations, shortness of breath, or weakness. The patient denied fever, headache, abdominal pain, nausea, vomiting. The patient was afebrile, blood pressure was 160/84, respiratory rate 16, pulse rate 84 beats per minute (bpm), oxygen saturation 96% on room air. The head, eyes, ears, neck, throat (HEENT) exam was within normal limits. The neck exam was unremarkable. Lungs were clear to auscultation. The cardiac exam revealed irregular rhythm, there were no murmurs. The abdominal exam was unremarkable. The patient had normal peripheral pulses. 

The patient was admitted to the telemetry floor for continuous cardiac monitoring. She received pain medications for the knee and ankle pain. According to the admitting physician, there was no evidence of alcohol withdrawal symptoms at the time of the exam. 

During the hospital stay the patient was seen by a cardiologist. There were no specific recommendations in regard to additional testing or intervention during the hospital stay. 
The patient was also seen by an orthopedic surgeon who diagnosed the patient with a left knee sprain. The orthopedic surgeon recommended a knee brace and non-weightbearing, with the use of a walker and crutches as well as the application of ice and pain control. There were no recommendations for any intervention during hospitalization. An outpatient follow-up was recommended. Since the patient remained in stable clinical condition, she was discharged from the hospital. 

The health plan's determination is upheld in whole. 

The admission at the acute inpatient level of care was not necessary in this case, based on the severity of the patient's condition and the complexity of the services provided.
This patient presented to the hospital after she had a single episode consistent with syncope, which was most likely related to alcohol intoxication. 

At the time of the admission, this patient was afebrile, hemodynamically stable, had a normal neurologic exam and unremarkable laboratory studies and diagnostic tests.
In order to see if the patient required admission at the acute inpatient level of care, the San Francisco Syncope Rule was used. This is a risk stratification tool that predicts risk for serious outcomes at 7 days in patients presenting with syncope or near-syncope.
Based on the calculations, the patient received zero points. That means that the patient belonged to a low-risk group for serious outcomes. 

In general, low-risk patients do not require treatment at the inpatient level. In this particular case, it was reasonable to admit the patient to the hospital for a short period of monitoring to rule out an injury that would require surgical intervention, and also watch for alcohol withdrawal symptoms, however this did not require an inpatient stay.