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 female teenager that was taken to the ED via EMS after a syncopal event followed by altered mental status. She had run two blocks then stopped suddenly, leaned up against a wall, and fainted. The patient did not fall to the ground or hit her head. The episode was witnessed by her father. Her father reported that she was difficult to arouse for about thirty minutes after the event. The patient reported feeling dizzy prior to the episode. The patient had one prior episode of fainting two months prior prompting evaluation by Pediatric Cardiology, a normal echocardiogram, and a Holter monitor revealing prolonged PR interval. 

The patient's vital signs in the ED included temperature 37.0, heart rate 73, respiratory rate 18 with 97% saturation in room air, and blood pressure 110/74. The patient's examination was significant for no distress, moist mucous membranes, regular heart rate and rhythm with no murmur, normal peripheral pulses, clear lungs, benign abdomen, and non-focal neurologic exam. Screening labs revealed normal metabolic panel, normal complete blood count, normal bedside glucose (93), and negative urinalysis. Electrocardiogram revealed normal sinus rhythm with rate 79, normal QTc (396), and PR interval 365. After discussing the case with Cardiology, the decision was made to observe the patient overnight in the hospital for possible underlying arrhythmia. 

Admission orders included telemetry, consideration for echocardiogram, consideration for video EEG, regular diet, and maintenance IV fluids. Cardiology was consulted with recommendations for an echocardiogram, subsequently done and normal. Neurology was consulted with recommendations for video EEG and imaging. The video 24-hour EEG was normal in the awake, drowsy, and asleep states with no evidence of seizures. The MRI and MRA were both unremarkable. The patient's appetite improved and she had no further spells. The patient was deemed stable for discharge.

No, the proposed inpatient admission is not medically necessary.

This patient had experienced an episode of syncope prior to this admission, with work-up including EKG revealing first degree heart block. This was her first episode of exertional syncope. She had been running when she felt dizzy, leaned up against a building, and fainted. Her father witnessed the event, and found her to be difficult to arouse for thirty minutes after the spell. By the time she arrived in the ED, she was alert and interactive with a non-focal neurologic exam. Because of the nature of the spell, she was admitted for overnight observation to include both Cardiology and Neurology consultations. Testing was completed (echocardiogram, MRI/MRA, video EEG) and the patient was discharged to follow-up in the outpatient setting. 

While it was medically necessary to monitor this patient because of her medical history and prolonged arousal time, she was overall hemodynamically stable, with no further spells and no history of seizures or trauma. The patient did not require acute inpatient admission and could have been safely managed at a lower level of care such as observation.