Appeal type: Medical necessity
Decision: Upheld

The patient is a female with a history of hypertension who presented to the hospital with a syncopal episode while at work. The incident occurred while sitting at the desk listening to a lecture, with sudden lightheadedness, numbness and tingling to the extremities, and shaking and feeling cold. She was laid out on the sofa before she could fall from the seat, and then regained consciousness reasonably quickly after that. However, she remained somewhat confused for about 20 minutes post the event. The patient reports unable to focus on the conversations of the people who are hovering over her while this acute episode was occurring. The patient reported significant psychosocial stressors in the immediate past, and inadequate dietary intake of food and fluids.
Cardiology evaluated the patient who described prior episodes of syncope with a traumatic fall causing a rib fracture. The cardiology team noted no cardiac murmurs on their exam documentation. Based on the documented assessment and plan, the cardiologist suspected orthostatic hypotension in the setting of dehydration as the cause of the syncope. They recommended consideration for neurologic evaluation secondary to the post syncope confusion episode.
The neurology team evaluated the patient and found no neurologic deficits on the exam. The repeat sodium levels normalized at 138 and a blood urea nitrogen (BUN) to creatinine ratio normalized as well. The neurology team recommended obtaining a brain magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA), and if normal, outpatient follow-up. The patient continued to complain of dizziness, and an overnight evaluation stated that the patient had lateral gaze nystagmus on the left side. The patient was evaluated by physical therapy, and found to have vestibular dysfunction, and recommended ongoing vestibular rehabilitation. The results of the MRI and MRA were unrevealing. An echocardiogram showed a preserved ejection fraction, and the cardiac enzymes were unremarkable. Orthostatic blood pressures were checked, and they were normal. Cardiac telemetry monitoring reveals sinus bradycardia with heart rates in the 50s, with a documented range between admission and discharge of heart rates between 53 and 83 beats per minute (bpm). The cardiology team did not find an indication for further electrophysiologic testing or insertion of a cardiac pacemaker.
The following day, symptoms were dramatically improved. Though not documented in the history and physical, the patient was started on empiric IV ceftriaxone for possible urinary tract infection. She completed a 3-day course in the hospital. The patient was deemed stable for discharge to home.

The health plan's determination is upheld.

The requested health service/treatment of inpatient hospital stay is not medically necessary for this patient. The documentation supports treatment at a lower level of care status. This presentation of syncope is not associated with any sort of hemodynamic instability or persistent alteration of mental status. A diagnosis of stroke, pulmonary embolism congestive heart failure (CHF), or acute coronary syndrome is not established. There is no evidence of severe structural heart abnormalities or critical conduction cardiac disease. Though the patient has borderline bradycardia, with a few heart rates in the 50s, the heart rate never dipped down below 50, and there is no associated hypotension with this event. The cardiology team that evaluated the patient did not determine the bradycardia is responsible for the patient's syncope. No additional electrophysiologic studies were required, nor insertion of a pacemaker. The patient had dehydration on admission, which was rapidly corrected within 24 hours. There was no injury caused by the syncope that required further hospitalization. The initial dehydration was rapidly corrected with gentle IV fluids within 24 hours. The entire neuroimaging evaluation was benign. Vestibular dysfunction is typically treated in a lower level of care setting.
In conclusion, clinical indications for admission to inpatient hospitalization are not satisfied.