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 who presented to the emergency department with concerns for an episode of unwitnessed syncope the day prior. Pertinent history included prior syncope, seizure disorder, substance abuse, psychiatric disorder, and chronic pain. Initial vital signs revealed a temperature of 98.6 Fahrenheit (F), heart rate (HR) 96, blood pressure (BP) 139/96, respiratory rate (RR) 17, peripheral capillary oxygen saturation (SpO2) 98%(percent) on room air. Initial examination documented the patient as alert and oriented with right periorbital ecchymosis. Initial laboratory testing revealed a white blood cell (WBC) count of 16.4, hemoglobin (Hgb) 13.3, blood urea nitrogen (BUN) 14, creatinine (Cr) 0.76, glucose (Glu) 128, sodium (Na) 136, potassium (K) 3.9, Lactate 1.7, and Troponin negative. Electrocardiogram (EKG) revealed normal sinus rhythm with a left posterior fascicular block. Chest radiograph unremarkable. Computed tomography (CT) head was unremarkable. CT of the facial bones was unremarkable. CT of the cervical (C)-spine unremarkable. The patient was hospitalized with an impression of fall with possible loss of consciousness. Treatment plan included intravenous fluids, telemetry, echocardiogram, electroencephalogram (EEG), and therapy services. The next day no episodes of syncope were documented. The patient left against medical advice. He was documented as clinically stable and ambulated out of the hospital on his own. The subject under review is the medical necessity for the inpatient admission.

The requested inpatient admission was not medically necessary.

Based on the clinical documentation provided, evidence based literature and standards of care, acute inpatient level of care was not indicated as medically necessary for the entire admission. Evaluation and management could have been performed at a lower level of care.

Runser et al. published guidelines in regard to the evaluation and management of Syncope. They 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]

The patient had a history of seizure disorder and psychiatric disorder who presented to the emergency department on his own and stated he had an episode of syncope the day prior. Initial examination documented the patient as alert, oriented, and hemodynamically stable. Initial evaluation including laboratory testing, electrocardiography, and CT imaging was essentially unremarkable. The admitting physician documented a low suspicion for a cardiac etiology. Treatment plan thereafter included telemetry, additional diagnostic testing, and observing. No episodes of syncope were noted. The patient became irritable and ambulated out of the hospital without issue and against medical advice. No other issues or complications were documented.
Moreover, clinical indications for admission to inpatient care were not met. [2]