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 with past medical history (PMH) of hypertension (HTN), atrial fibrillation (A-fib), uncontrolled diabetes mellitus, chronic kidney disease (CKD), right eye blindness, recurrent stroke with right-sided residual weakness, chronic obstructive pulmonary disease (COPD), cervical radiculopathy with history of fusion surgery, depression, alcohol abuse, opioid dependence, and wheelchair dependent.  

The patient presented to the emergency department (ED) after a fall when he was trying to get up from the bed and fell on the floor. Not much history was available, as he was sleepy likely due to the use of Percocet and Benadryl on the morning of arrival, but he complained of neck pain that was ten out of ten (10/10) in intensity and insomnia and denied any loss of consciousness. On arrival, blood pressure was 108/64, pulse oximetry was 97% in room air (RA), pulse was 86, respirations were 18, and temperature was 98.1. Physical exam was grossly unremarkable, no injury was noted, his right-sided extremity was weaker compare to the left. Blood glucose was 477 and creatinine was 2.63. 

The patient was admitted to the telemetry floor with a working diagnosis of presyncope/fall and uncontrolled diabetes mellitus. Urine toxicology was positive for opioid; electrocardiogram (EKG) and chest x-ray (CXR) were normal. The patient was continued on intravenous (IV) fluid, insulin, and diabetic diet, and his pain medication was tapered. Lisinopril was held due to worsening renal function. The patient underwent computed tomography (CT) of the brain, maxillofacial region, and cervical spine - those were reportedly unremarkable. The patient remained stable and renal function improved with hydration; repeat creatinine level was 1.92, and blood glucose also improved. He was counseled for decreasing the dose of pain medications, diabetic diet, and insulin compliance; he agreed with the plan. The patient was cleared for discharge with a plan for outpatient follow-up with his primary medical doctor (PMD).

No, the proposed Inpatient Emergency Room Admission was not medically necessary.

The patient is a Male with significant comorbidities who is wheelchair-bound and presented to emergency room (ER) after a fall when he was trying to get up from the bed. The patient reported neck pain and insomnia; he was taking pain medications at home. His physical exam and vitals were fairly stable in the Emergency room. Electrocardiogram (EKG), chest x-ray, and computed tomography (CT) scan were unremarkable without any evidence of injury. Blood work showed blood glucose of 478 , creatinine was 2.63 and sodium was 135 (likely due to elevated blood glucose). The patient was admitted with a diagnosis of fall due to presyncope/syncope and uncontrolled diabetes mellitus.  The patient received intravenous (IV) fluid and insulin with the improvement of renal function and glucose level. His cardiac workup was negative. The fall was later thought to be due to pain medication so it was tapered prior to discharged and the patient was counseled. Subsequently, the patient was discharged with advice for follow-up as an outpatient with his primary care. 

As per Medscape, inpatient admission for syncope should be reserved for patients in whom identification of specific immediate risk is needed (eg, those with structural heart disease or a history of ventricular arrhythmia). Outpatient management can be used for patients who are at low risk for a cardiac etiology to define a precise cause so that mechanism-specific treatment can be affected. This patient had none of the clinical conditions mentioned that warranted inpatient care, rather he could be managed in a lower level of care. Therefore, inpatient admission was not medically necessary.