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 male. He had a tantrum because he was denied something. During the tantrum, he retched three times then lost consciousness for 5 minutes. He did not respond to sternal rub or splashes of water. Caretakers took him to the ED (emergency department).

In the ED (emergency department), the patient was sleepy. His vital signs and physical examination were normal. An ECG (electrocardiogram) showed inverted T waves, incomplete right bundle branch block, and a 2/6 systolic murmur. He received a bolus of IV (intravenous) fluids. He was admitted to telemetry and made NPO (nothing by mouth). Cardiology evaluated him deemed him safe for discharge to home.

The patient remained stable overnight and was discharged to home.

No, the Inpatient admission was not medically necessary.
Admission for syncope is indicated for 1 or more of the following (1):

1) Hemodynamic instability
2) Altered mental status that is severe or persistent
3) Diagnosis requiring inpatient admission, as indicated by 1 or more of the following:
   a)	CNS (central nervous system) event or pathology (eg, hemorrhage, mass, hydrocephalus).
   b)	Arterial dissection
   c)	Anemia secondary to acute blood loss (eg, gastrointestinal bleed). See Gastrointestinal Bleeding, Upper or Gastrointestinal Bleeding, Lower guideline.
   d)	Other diagnosis or finding necessitating inpatient care
   e)	Cardiac disease or finding (eg, results of echocardiogram or cardiac monitoring performed in observation care) that indicates necessity of immediate (ie, not as a scheduled elective procedure) intervention (eg, AICD [automatic implantable cardioverter defibrillator] placement, electrophysiologic studies, surgery, prolonged telemetry monitoring), as indicated by 1 or more of the following:
		  1) Outflow tract obstruction (eg, hypertrophic cardiomyopathy)
		  2) Structural abnormality (eg, certain congenital heart defects, ventricular dysfunction, cardiomyopathy)
		  3) Valvular disease (eg, aortic stenosis, prosthetic valve dysfunction)
		  4) Myocarditis
		  5) Subclavian steal syndrome
		  6) Cardiac tamponade or constrictive pericarditis
		  7) Primary pulmonary hypertension
		  8) Other finding indicative of cardiac etiology of syncope (eg, results of electrophysiologic studies)
4) Cardiac ischemia
5) Sustained or symptomatic ventricular tachycardia (VT)
6) 	Symptomatic conduction system disease or Mobitz II or third-degree heart block
7)	Bradycardia or sinus pauses (ie, not related to neurally mediated syncope)
8)	Supraventricular tachycardia. See Supraventricular Arrhythmias guideline
9)	Atrial fibrillation with rapid ventricular response. See Atrial Fibrillation guideline
10)	Pacemaker or AICD (automatic implantable cardioverter defibrillator) malfunction
11)	Inheritable cardiovascular condition predisposing to arrhythmias diagnosed or suspected (eg, Brugada syndrome, short QT syndrome, long QT syndrome)
12) Dehydration that is severe or persistent
13) Syncope causing injury requiring hospitalization

The clinical records provided fail to document the patient meeting any of the above criteria. Thus, inpatient was not medically necessary, appropriate, or standard of care.

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.