Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Syncope with Head Trauma

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This elderly patient presented to the hospital after syncope with resultant head trauma.  The patient was standing in the kitchen, washing dishes, and developed chest pain and lightheadedness and then fell to the ground.  The patient reports watery diarrhea for several days prior to presentation.  Past medical history was significant for mild aortic stenosis and moderate aortic insufficiency, hypertension, and hyperlipidemia.  On arrival to the hospital vital signs were stable (BP [blood pressure] 157/71, Pulse 69).  Physical examination was significant for a "golf ball sized" soft tissue swelling along the left parietal area of the skull. There was also diffuse tenderness along the left shoulder and wrist and mild tenderness along the left hip. 12 lead electrocardiogram revealed normal sinus rhythm with right bundle branch block and occasional premature ventricular contractions.  The echocardiogram performed six months earlier noted a left ventricular ejection fraction (LVEF) of 58% (percent), mild aortic stenosis (AS) and moderate aortic regurgitation (AR) with diastolic dysfunction. Serum blood testing revealed a hemoglobin of 12mg/dl (milligrams per decilitre), no elevation in serum troponin (8) and mild hypokalemia (K 3.3). The patient was admitted to the hospital for additional testing.  X-rays of the upper and lower extremity revealed no evidence of fracture.  Computed tomography (CT) of the head demonstrated no intracranial pathology.  Repeat blood work the next day was concerning for a drop in hemoglobin but ultimately was deemed to be due to lab error.  

This patient presented with lightheadedness and near syncope. Given right bundle branch block and premature ventricular contractions (PVC) on electrocardiogram, cardiac syncope was a concern.  The patient was also treated with intravenous fluids as there was concern for volume depletion.  Potassium supplementation with cardiac monitoring was also necessary.  This patient falls into a moderate risk group for syncope.  According to the European Society of Cardiology, patients presenting with syncope must be risk stratified for future morbidity and mortality in order to determine the need for hospital admission. (Reference 1)

In a study of individuals presenting to the emergency room, patients that were moderate or high risk for cardiac events had a poor prognosis and required admission to the hospital for additional testing and treatment. (Reference 2)  

In this case, the patient was elderly and sustained head trauma. The patient had evidence of His-Purkinje disease on electrocardiogram. Despite the fact that this patient's syncope may have been due to volume depletion the differential diagnosis included high risk cardiac conditions such as heart block and a higher level of care was indicated.  Inpatient admission to the hospital for treatment and risk stratification was medically necessary in this case.

Based on the above, the insurer's denial is reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an inpatient admission is substantiated.