Appeal type: Medical necessity
Decision: Upheld

This is a patient with a past medical history significant for hypertension, hyperlipidemia, diabetes mellitus, end-stage renal disease on hemodialysis, and coronary artery disease who presented to the hospital with a history of a syncopal episode. Reportedly, the syncopal episode occurred 3 days before the patient decided to come to the emergency department. According to the records, the patient was sitting on his bed, and then he got up in order to walk to the kitchen. The next thing he remembered was being on the ground with a bloody nose and mouth.
When asked, the patient denied any prodromal symptoms including headache, dizziness, chest pain, palpitations, shortness of breath, or seizure-like activity that were associated with the fall.
Subsequently, the patient shared the information about the fall with his daughter, who advised him to come to the emergency department. The review of systems was negative for a fever, chills, nausea, vomiting, diarrhea, abdominal pain. The patient's last hemodialysis session was after he had the fall.
The patient looked nontoxic, resting comfortably in bed. He had a bruise on the forehead. head, eyes, ears, neck, throat (HEENT) exam was positive for raccoon eyes.
The patient had no jugular vein distention (JVD). Lungs were clear to auscultation bilaterally, cardiovascular exam was unremarkable. The abdominal exam was within normal limits. The neurologic exam was nonfocal.
Laboratory evaluation demonstrated that the sodium was 134, potassium 5.4, chloride 93, bicarbonate 29, blood urea nitrogen (BUN) 46, creatinine 5.19, and glucose 136. The white blood cell count was 17.2, hemoglobin 10.1, hematocrit 32.9, and platelets 209.
An electrocardiogram (EKG) showed normal sinus rhythm, 68 bpm.
A computed tomography (CT) scan of the facial bones demonstrated mild right periorbital soft tissue swelling. CT scan of the head was negative for bleed, but showed some paranasal mucosal inflammation with near-complete opacification of the right maxillary sinus. CT scan of the chest was negative for rib fractures, however it showed bilateral upper lobe solid lesion, which likely represented scarring. CT scan of the abdomen and pelvis with contrast was unremarkable for any acute pathology. CT scan of the cervical spine, x-ray of the pelvis, x-ray of the wrist were negative.
After evaluation in the emergency department, the patient was admitted to the medical floor for investigation of his syncopal episode and because of the fall and orthostatic syncope. While in the hospital, his blood pressure was checked for orthostatic changes and reportedly was normal.
The patient was admitted for telemetry monitoring and evaluation by physical and occupational therapy. His leukocytosis was attributed to stress and was determined unlikely to be infectious.
During the hospital stay, the patient underwent a doppler ultrasound of the carotid arteries that demonstrated moderate to severe bilateral stenosis. This was evaluated by vascular surgery. Due to the patient's multiple comorbidities, he was determined to be at high risk for any surgical intervention.
The health plan's determination is upheld.
The patient presented to the hospital with a history of a single syncopal episode that he sustained 3 days before the day of admission. At the time of the initial evaluation, the patient was afebrile and hemodynamically stable. His blood pressure was on the high side, and there was no evidence that he had orthostatic hypotension or bradycardia.
The review of systems was negative for chest pain, shortness of breath, palpitations. The physical exam performed at the time of admission did not reveal any alarming findings. The results of the laboratory evaluation did not show significant anemia. The patient's troponin was minimally elevated which is common in the setting of chronic kidney disease.
Even though the patient had leukocytosis, there was no evidence of an acute infection.
Considering that the patient had possible EKG changes, telemetry monitoring, to rule out acute coronary syndrome, and ensure overall clinical stability, was reasonable. At the same time, neither the severity of the clinical condition nor the complexity of the services provided justified admission at the acute inpatient level of care. The patient had no recurrent syncopal episodes or any concomitant conditions necessitating admission at the acute inpatient level of care. Care could have been provided at lower level than inpatient.

The health plan's determination of medical necessity is upheld in whole. The review of the medical records demonstrated that neither the severity of the patient's condition nor the complexity of the services provided justified admission at the acute inpatient level of care.