Appeal type: Medical necessity
Decision: Upheld

Central Nervous System - Other
Inpatient Hospital

The patient is a female with a past medical history significant for diabetes mellitus and hypertension who presented to the emergency department after she sustained a near-syncopal episode.
Reportedly, the patient bent down to pick something up from the shelf in Walmart, when she started to experience symptoms that included transient confusion and lightheadedness. For a short period of time, the patient was unaware of where she was.
Laboratory evaluation revealed that white blood cell count was 4.5, hemoglobin 12.7, hematocrit 39.2, platelets 144. Sodium was 138, potassium 4.2, chloride 107, bicarbonate 25, blood urea nitrogen (BUN) 18, creatinine 0.8, glucose 188. Troponin was normal, liver function tests were unremarkable.
Electrocardiogram (EKG) demonstrated sinus bradycardia. On the first EKG, the patient's heart rate was 45 beats per minute, at the same time, there were no changes consistent with ischemia.
Computed tomography (CT) scan of the head, CT angiogram of the head and neck did not show acute abnormalities.
Magnetic resonance imaging (MRI) of the brain was subsequently performed and did not reveal any acute abnormalities.
In the hospital, the patient was seen by a cardiologist who stated in the consultation that the patient's symptoms were most likely related to vagal mediated response. Although some suspicion for symptomatic bradycardia existed, the cardiologist recommended to repeat serial EKGs, continue monitoring, check blood pressure for orthostatic changes, continue Lisinopril and Aspirin, administer intravenous fluids. At the time the patient was seen by the cardiologist, her heart rate was in the 60s.
The patient was also seen by a neurologist who examined the patient and reviewed the diagnostic studies and concluded that the patient had no focal weakness or numbness, headache or visual changes, speech or language disturbances.
The neurologist stated that the differential diagnosis in this clinical case was broad and included metabolic derangement, hemodynamic instability, and near syncope, transient global amnesia, transient ischemic attack (TIA), migraine phenomena, seizure. Echocardiogram and a 24-hour electroencephalogram (EEG) were recommended and performed.
These studies were unremarkable.
In the hospital the patient remained in stable clinical condition, therefore she was discharged home.

The health plan's determination is upheld.

This patient presented to the hospital with sudden onset of lightheadedness and altered mental status that manifested in mild confusion. These symptoms were transient and pretty much resolved by the time the patient was admitted to the hospital.
The results of the physical exam, laboratory tests, and diagnostic tests did not point to any clinically significant abnormalities that would require admission for treatment at the acute inpatient level of care. The patient underwent a number of diagnostic studies that were appropriate for her condition in order to establish the correct diagnosis. Neither of these diagnostic studies required admission at the acute inpatient level of care.
The patient's bradycardia that was present on admission improved and the heart rate was in the range between the '50s and '60s. Regardless of the presence of mild bradycardia, there were no specific treatments provided in the hospital to treat the bradycardia.
Taking into consideration all these facts, it is clear that neither the severity of the patient's condition nor the complexity of the services provided justified admission at the acute inpatient level of care.
The admission for monitoring was appropriate, especially for cardiac monitoring as well as neurochecks, but this could have been provided at a lower level of care.