Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope
Treatment: Inpatient Stay
The insurer denied the Inpatient Stay.
The decision is upheld.


The patient presented to the hospital after he had a syncopal episode. Reportedly, the patient was at work when he started to feel lightheaded and passed out. He vomited afterward. The review of systems was negative for preceding chest pain, shortness of breath, palpitations, fever, chills, headache, blurry vision, or nausea.
Reportedly, the patient noticed bright red blood per rectum the morning of the day of admission; possibly related to some injuries that the patient sustained from insertion of a foreign body in the rectum the day before. The patient also complained of abdominal pain located in the lower abdomen but denied any urinary complaints, testicular pain, penile discharge. The patient reported methamphetamine use several days before the presentation.
At the time of the initial evaluation, the patient was afebrile, his heart rate was 84 beats per minute (bpm), respiratory rate 14, blood pressure 121/61, and oxygen saturation 96% on room air. The patient was in no acute distress, appeared to be well developed. He was not diaphoretic. The head, eyes, ears, neck, throat (HEENT) exam was within normal limits, the cardiovascular exam was unremarkable. The lungs were clear to auscultation. The patient had some tenderness to palpation in the lower abdomen, more on the left side, without guarding or rebound. The patient had a brown stool on the rectal exam. The rest of the physical exam was unremarkable.
An electrocardiogram (EKG) demonstrated normal sinus rhythm. The patient was admitted to the hospital and received treatment with intravenous fluids. A computed tomography (CT) scan of the abdomen and pelvis was ordered because of the concerns of intestinal perforation. The CT scan of the abdomen and pelvis demonstrated that the patient had a 10 centimeter (cm) acute hematoma in the abdominal cavity along with associated moderate volume fluid that likely contained blood around the liver and spleen. There was no definite acute vascular bleeding source identified. The bleed was attributed to the tearing of the upper perirectal vessel. There was no free air.
During the hospital stay, the patient was evaluated by general surgery. The surgeon recommended observation. There was no need for surgical intervention. It was recommended to get another complete blood count (CBC) in six hours to make sure that the hemoglobin and hematocrit (H&H) remained stable.
From the ER, the patient was transferred to the observation unit for further management.
Upon arrival at the unit, the patient reported feeling dizzy with worsening abdominal pain. His blood pressure was checked for orthostatic changes and that study revealed that the patient was orthostatic.
During the period of observation, the patient's condition significantly improved, including the resolution of orthostatic hypotension. During the hospital stay, the patient's hematocrit remained stable and the patient did not require any transfusion of packed red blood cells. There were no complaints of rectal bleeding or melena. Prior to the discharge, the patient tolerated his diet. At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient stay was not medically necessary for this patient.
In this clinical case, the patient presented to the hospital due to a syncopal episode that occurred as a result of orthostatic hypotension caused by acute blood loss anemia. Acute blood loss anemia was a result of the tearing of the upper perirectal vessel, which occurred as a result of the insertion of a foreign body in the rectum. Despite the fact that the patient developed an intra-abdominal hematoma, he still remained in stable clinical condition. His bleeding resolved without any intervention. The patient was seen by surgical service and was recommended observation and close monitoring.
Taking into consideration this information, based on the severity of the patient's condition and the complexity of the services provided, care could have been provided at a lower level.
Even though the patient was anemic, his hematocrit remained stable throughout the entire period of hospitalization. There was no need for surgical intervention. The patient did not need invasive blood pressure monitoring or treatment with pressors. Based on the evaluation of the surgical team, it was determined that the patient was not actively bleeding. 
By the time the patient came to the hospital, he was not actively bleeding since his hemoglobin and hematocrit (H&H) remained stable. The patient's orthostatic hypotension, which was related to acute blood loss anemia, resolved by the time of the discharge. The patient did not require any surgical intervention and was able to eat his meals. There were no concomitant conditions that would justify admission at the acute inpatient level of care. The main reason for admission was the monitoring of hemodynamic stability and a possible extension of intra-abdominal hematoma and worsening anemia.