Appeal type: Medical necessity
Decision: Upheld

Diagnosis: tachycardia and dizziness

Treatment: inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

This is an adult male with a history of hypertension, hyperlipidemia and diabetes who presented to the Emergency Department (ED) with tachycardia and dizziness. His blood pressure (BP) was mildly elevated, and his heart rate (HR) was 122 beats per minute. He complained that dizziness was present with movement and would stop after a few seconds. There were no documented episodes of chest pain, heart palpitations, nausea, vomiting or fainting. An electrocardiogram (ECG), chest x-ray and an echocardiogram were all unremarkable. He was diagnosed with orthostasis due to hypovolemia and diuretic use. Laboratory values were normal. He was administered intravenous (IV) fluids, aspirin, losartan and atorvastatin. 

There were no recurrent syncope or imminently dangerous cause. In this setting an acute inpatient level hospitalization, compared to observation, has not been established as standard of care towards improved cardiac outcomes. 

Per Davis, A. J., & Pozun, A., "Dizziness as a patient complaint can refer to many different sensations, including lightheadedness, vertigo, or unsteadiness....Orthostatic Hypotension can be improved by increasing water intake, reviewing the medication list, making lifestyle changes, and in some cases adding Midodrine or a mineralocorticoid to the patient's medication regimen."

"Syncope is a transient loss of consciousness and postural tone followed by spontaneous recovery. While there are numerous classification schemes used to further identify and manage underlying conditions that may lead to syncope, syncope ultimately results from decreased cerebral perfusion. Syncopal episodes may occur suddenly and without preceding signs or symptoms or may be preceded by dizziness, lightheadedness, diaphoresis, nausea, visual disturbances, or other signs and symptoms. Patients may describe syncopal events in a wide variety of ways, some of which include fainting, blacking out, falling out, having a spell, or losing consciousness. Syncope is responsible for 1 to 3.5 percent of all emergency department visits and 6 percent of all hospital admissions in the United States." (Grossman SA, Badireddy M.).

Per Shen, W. K., et al, "Dizziness, with its myriad of etiologies, often requires interprofessional care. With the numerous possible causes of dizziness, interprofessional communication is vital to proper patient care and good outcomes. Whether in the ER (emergency room) or office setting, the entire healthcare team plays an essential role in helping to differentiate the cause of dizziness....Syncope related to medication becomes prevalent particularly in older adults, who frequently have multiple comorbidities requiring treatment and are prone to polypharmacy effects.488-490 Cessation of offending medications is usually key for symptomatic improvement, but often feasibility of cessation of medications is limited by the necessity of the treatments...Most commonly, the symptoms include lightheadedness, palpitations, tremulousness, generalized weakness, blurred vision, exercise intolerance, and fatigue."

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient admission is not substantiated.