Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory.
Inpatient Hospital.

Diagnosis: Syncope.
Treatment: Inpatient Hospital Stay.
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

This is a male patient who presented to the emergency department (ED) after an episode of diarrhea followed by lightheadedness and syncope. He reported striking his head when he fell and complained of a headache, neck pain, and nausea. His medical history was remarkable for obstructive sleep apnea, anxiety, and recurrent vasovagal syncope. He was afebrile. His physical exam revealed a scalp contusion and was otherwise unremarkable. His electrocardiogram was normal. His troponin I level was mildly elevated at .083 nanograms/milliliter (ng/ml). Head and cervical spine computed tomography (CT) scans showed no acute pathology. The patient had 23 millimeters of mercury (mmHg) drop in his systolic blood pressure when moving from a supine to a standing position. He was treated with aspirin and intravenous saline and was admitted to the hospital. Repeat troponin levels were .060 ng/ml and .036 ng/ml. He was seen in consultation by a cardiologist and a neurologist. His loss of consciousness was attributed to vasovagal syncope. The patient was discharged. The medical necessity for an inpatient admission is an issue.
Based on the documentation provided an inpatient level of care was not medically necessary.
This patient presented after an episode of syncope He was hemodynamically stable, with a normal electrocardiogram. While his serum troponin level was minimally elevated, it was not diagnostic of an acute myocardial infarction. He had a history of recurrent vasovagal syncope. The literature does not adequately describe which patients will benefit from inpatient hospital admission or observation nor has it demonstrated the value of admission in preventing future adverse outcomes. However, certain features have been identified as signifying high risk. These include exertional syncope, known structural heart disease, age greater than (>) 60 years, and a family history of sudden cardiac death. This patient had none of these features. Per the 2017 American College of Cardiology/American Heart Association/Heart Rhythm Society (ACC/AHA/HRS) Guideline for the Evaluation and Management of Patients with Syncope, inpatient admission is recommended for patients presenting with syncope who have a serious medical condition potentially relevant to the cause of syncope identified during the initial evaluation. This patient had no such condition identified. The document further states, "In intermediate-risk patients with an unclear cause of syncope, use of a structured ED observation protocol can be effective in reducing hospital admission. Two small randomized controlled trials suggest that structured ED-based protocols, consisting of time-limited observation and expedited access to cardiac testing/consultation, result in reduced health service use without adverse impact on clinical outcomes when compared with unstructured hospital admission." Thus, based on the information provided, an inpatient level of care was not medically necessary for this patient.