Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a male. He was brought to hospital with complaints of dizziness and passing out. He has history of hypertension, vertigo, and obesity. The patient described his event as occurring after a shower, when he became dizzy and fainted. 

The patient was mildly hypertensive on admission and was in normal rhythm. The
patient described himself as "cloudy." Multiple labs were ordered, most of which
were normal; His rhythm was monitored and was found to be unremarkable. The
working diagnosis was vasovagal syncope. EKG (electrocardiogram) showed NSR
(normal sinus rhythm) without ectopy or pauses. Cardiac enzymes were negative.
CXR (chest x-ray) was negative. His CT (computed tomography) head was
negative. 

In the ED (emergency department), the patient received IV (intravenous) NS
(normal saline), and an aspirin. Cardiology and neurology consults were performed. 

The patient was admitted to telemetry, where he received IVF (intravenous fluids),
ASA (aspirin), and an ACE (angiotensin-converting enzyme). He was discharged
with presumed diagnosis of vasovagal syncope. 

No, the Inpatient admission was not medically necessary. 

Determination of level of care is primarily dependent on the actual care a patient
receives, and whether a higher level of acuity is needed to give this care. This is
best reflected in the presentation, physical exam findings, and laboratory orders
and their results. It is highlighted in the orders for care. 

In this case, the patient's symptoms were consistent with a vasovagal reaction, i.e.
a simple faint. This is not uncommon after a shower. The patient did not lose
bladder or bowel control. No evidence of any arrhythmia was noted, nor did the
patient have palpitations or near syncope in the past. No EP (electrophysiology)
consult was obtained (or necessary), and no complex work up for syncope was
entertained or performed. 

The patient's symptoms were very atypical for arrhythmia and unlikely to be
representative of acute coronary syndrome. The patient's exam (blood pressure
normalized) and cardiac findings were normal. Biomarkers and EKG
(electrocardiogram) showed no evidence of acute ischemia. CXR (chest x-ray) was
normal. The physicians' treatment did not reflect any serious concern about the
patient's cardiac condition. Progress note suggested discharge. 

The appeal was carefully considered, but it offered no evidence to support a higher
level of care. The only care provided was telemetry, which is frequently performed
in observation and outpatient status. The patient was admitted for monitoring, and
the subsequent tests and therapy did not require an inpatient level of care. There
was no complex care that required inpatient care. While there was always a
potential for an adverse event (and in this case a very low probability), one did not
happen and no actual treatment was added. It may have been appropriate to
discharge this patient immediately as low probability of cardiac event. 

Milliman criteria requirements for syncope inpatient admission were not fulfilled. All
testing and therapy would be appropriate, safe and guidelines consistent to be in an
outpatient setting. Thus, inpatient level of care was not medically necessary. 

The denial explanation was consistent with guidelines and usual community care. It
is consistent with the American College of Emergency physicians' position on
treatment of how to work up syncope and near syncope. It was clearly an outpatient
level of care. 

Yes, the health plan did act reasonably, with sound medical judgment, and in the
best interest of the patient.