Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Syncope
Treatment:  Inpatient admission
The inpatient admission was medically necessary.

The patient is a male with multiple comorbidities including schizoaffective disorder, hypertension, atrial fibrillation (A-fib), coronary artery disease (CAD), congestive heart failure (CHF), diabetes mellitus, gout and status post (s/p) automatic implantable cardioverter defibrillator (AICD).  The patient presented to emergency room via EMS from a public housing facility after he had an episode of unwitnessed syncope.  The patient reported to the ED physician that he had generalized weakness and sweating, so he went out to have fresh air, later he felt nauseous and wanted to have bowel movement, went to bathroom, felt lightheaded and passed out for couple of minutes.  He noted a bout of mild shortness of breath prior to the episode, also had dyspnea on exertion for a few months and recent hospitalization for CHF exacerbation.  The patient denied any injury, vomiting or incontinence.  He admitted he was high on THC prior to the syncopal episode. 

In ER, vitals were stable without any orthostatic changes; the patient was alert and oriented, and exam was remarkable for mild bilateral basal crackles in the lung field.  Work up including troponin times two was negative, hemoglobin was 11.4 and platelets were 149.  Electrocardiogram (EKG) showed conduction delay with T-wave inversion in inferior leads and chest x-ray (CXR) showed mild pulmonary congestion.  Given the patient's comorbidities, the patient was recommended inpatient admission for evaluation of syncope, and he was continued on home medications.  AICD was interrogated, and it was essentially unremarkable except remote non-sustained ventricular tachycardia (VT).  Urine toxicology was positive for THC. 

The patient remained stable and did not need any intravenous (IV) Lasix, as his CHF was compensated.  Syncope was thought to be vasovagal or tetrahydrocannabinol (THC) related.  Accordingly, the patient was discharged with advice to follow as an outpatient. 

This male patient presented with complaints of unwitnessed syncopal episode in the setting of past medical history (PMH) of CAD, HTN, CHF, s/p replacement of AICD and A-fib.  Physical exam revealed mild basal crackles in the lung field, but vitals and cardiac troponin were normal.  EKG and CXR had minimal changes and proBNP was 3596.  The patient was recently admitted to another facility for exacerbation of CHF, but it was noted this time there was low suspicion for decompensation of CHF, so an echocardiogram (ECHO) was not ordered.  The patient was continued on his home medication and remained stable.  It is noted by the American College of Physicians (ACP) that syncope in the setting of CHF, high grade heart block, persistent systolic blood pressure less than 90 or heart rate less than 60, hematocrit less than 25 or acute gastrointestinal bleeding, etc. should be admitted in hospital for inpatient care.  Given this patient had significant cardiac history, the initial decision of inpatient admission was a medical necessity as per ACP hospitalist guidelines.  Given the above, the inpatient admission and the length of stay were consistent with the standard of care and generally accepted nationally recognized guidelines.