Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory-Syncope
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

At the time of her admission the patient was sent from her physician's office to the emergency department for evaluation of a fainting episode. The episode was witnessed by her mother. She was in the bathroom and slammed the door on her finger and "passed out" in front of her mother, who prevented her from having her head hit the floor. There was no generalized tonic clonic activity, no loss of bowel or bladder. She was fully awake within a minute. She said her periods had been irregular for two months and particularly heavy the week of the incident. Her blood pressure (BP) was 107/53 in a sitting position, heart rate (HR) 73. She was afebrile and had 100% (per cent) oxygenation on room air. An electrocardiogram (EKG) was normal. Her white blood cell count (WBC) and platelets were normal. Hemoglobin was 9.3. Glucose and metabolic panel were normal. Covid was negative. Urine pregnancy was negative. Her presumptive diagnosis was dysfunctional uterine bleeding with syncopal event. She was admitted to the pediatric ward. She was started on iron and norethindrone for dysfunctional uterine bleeding. She continued to do well the next day. She had a normal electroencephalogram (EEG). She was discharged home the next day on iron and norethindrone. 

The requested inpatient stay was not medically necessary for this patient.
The patient had a witnessed syncopal episode after slamming her finger in a door. She did not have seizure activity or hit her head. She had normal vital signs in the emergency department, a normal physical exam, and normal labs except for a modest anemia, which her caregivers explained as due to dysfunctional uterine bleeding. Iron and hormonal therapy were appropriately prescribed. She did not have any evidence of cardiac or neurologic problems. She was hemodynamically stable despite the mild anemia and did not have documented orthostatic hypotension or difficulty ambulating. The care necessary--iron and hormonal management--are lower level of care therapies. There was no necessity to start these medications as an inpatient and observe response. She did not require acute inpatient hospitalization as she had been fully evaluated and observed in the emergency department, and the necessary care--iron and hormonal therapy--could have been prescribed  and taken at a lower level of care.
The Milliman Care Guidelines (MCG) Syncope criteria state that inpatient hospitalization is considered medically necessary if there is a suspicion of imminent dangerous cause (pericardial tamponade, pulmonary embolism), injury requiring hospitalization, severe finding (e.g. persistent or severe hemodynamic instability, arrhythmia, respiratory distress, persistent or severe neurologic signs or symptoms, suspected structural cardiac disorder, severe electrolyte abnormality), or treatment requiring hospitalization (oxygen, intravenous (IV) fluid, IV anticoagulation, pacemaker, cardioversion). She met none of these criteria.