Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Cardiac/Circulatory Problems - Other.
Treatment:  Inpatient Hospital.

The insurer denied the inpatient hospital stay.  The denial was upheld.

The patient is a male with hypertension, who presented to the emergency department with a witnessed episode of syncope, without shaking or incontinence, lasting for about 2 to 5 minutes.  He was sitting in the synagogue and had a sensation of warmth overcoming him, but no palpitations preceding the event.  He recollects nothing over the next 2 to 5 minutes, and subsequently woke up.  The people that were surrounding him shook him up to wake him up.  When he came to his senses he was alert and oriented x3, with no confusion or amnesia.  The patient had a new diagnosis of hypertension and recently prescribed metoprolol but had not started taking it yet, and he had no prior episodes of symptoms like this.  Upon arrival in the ED, the only symptom was excessive tiredness.  He appeared to be only moving his right arm but not the left arm when EMS got on the scene, but by the time he was evaluated in the ED, he was moving all four extremities without difficulty.

Nonetheless, stroke alert was activated.  A computed tomography (CT) of the head was immediately done, and it was negative for acute intracranial pathology. The CT scan did show a suprasellar mass presence, concerning for adenoma.

An emergent MRI was ordered, along with CT angiogram of the head and neck that was negative for significant stenosis, or bleed.  The patient was deemed not a candidate for tissue plasminogen activator (TPA).

The patient was admitted with a principal diagnosis of syncope and collapse.  An echocardiogram was ordered, and an electroencephalogram (EEG) was considered to rule out seizures.  The brain MRI came back preliminarily as a pituitary macroadenoma.  Neurosurgery and endocrinology were consulted, and hormone levels were ordered, as well.

All of the studies were performed within 24 hours, showing mild bradycardia on telemetry.  The EEG did not show any evidence of epilepsy.  Thyroid stimulating hormone (TSH), prolactin level, luteinizing hormone (LH), and follicle-stimulating hormone (FSH) levels were all normal.  The human growth hormone level was also in the normal range.  As a result, neurology and neurosurgery recommended no acute intervention, with follow-up as an outpatient. 

After carefully reviewing the provided documentation clinical indications for admission to inpatient care were not satisfied.  The patient experienced no evidence of hemodynamic instability.  The altered mental status lasted for a few minutes, and subsequently the patient was documented as alert and oriented x3.  It is highly unlikely that the pituitary macroadenoma contributed to the patient's syncope.  It is a non-active macroadenoma, without hormonal disbalance.  Based on the clinical picture, this was an incidental finding of no consequence to the patient's presentation.  There was no evidence of stroke or bleed, which can cause syncopal spells.  The patient was not anemic, did not have heart failure symptoms, and did not require a pacemaker or automatic implantable cardioverter defibrillator (AICD) placement for the single episode of bradycardia.  After discontinuation of beta-blockers, the bradycardia resolved.  There was no evidence of atrial fibrillation with rapid ventricular response (RVR) or inheritable cardiovascular condition predisposing to arrhythmias, such as Brugada syndrome or long QT syndrome.  The patient did not appear dehydrated.  He did not suffer an injury from the syncope, requiring inpatient hospitalization.