Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld.

The patient presented to after an episode of fainting, with loss of consciousness. The patient had a laceration over the right eyebrow and complained of slight chest pain that began one month previously. At the time of presentation, blood pressure was 103/72 and the remainder of the patient's vital signs were normal. The patient described feeling lightheaded that day and had worsening chest pain. The chest pain had been present for weeks, since having a positive Covid test. Family history includes mother with recently diagnosed long QT syndrome with Torsade who now has an Implantable Cardiovascular Defibrillator (ICD). Patient has had months of syncope and lightheadedness. The patient complained of mild headaches and dizziness. The troponin was negative. The electrocardiogram (EKG) showed normal sinus rhythm without pathological ST segment or T wave changes. The QTc interval was normal. D-dimer was elevated. The computed tomography (CT) angiography of the chest was negative for pulmonary embolus. The laceration was treated with skin tissue adhesive. The patient had a second episode of syncope subsequently, witnessed by the emergency department provider. The patient was off the cardiac monitor at the time, but was noted to develop visible pallor on the face, and had a radial pulse in the 40s with an irregular rhythm. There were no signs of tonic-clonic convulsions or seizure activity. The patient was unresponsive for approximately 10 to 15 seconds with immediate return to baseline mental status. An EKG was performed after that showed sinus bradycardia at 49. The patient was placed on observation status for further workup.

An additional workup was performed. The patient was on telemetry, with no abnormal findings otherwise documented. Chest x-ray was negative. The patient remained in normal sinus rhythm and QTc intervals were documented as normal. The submitted records did not contain any EKGs or formal EKG report. 

The case was discussed with electrophysiology who recommended genetic testing. It does not appear that the patient was actually seen by electrophysiology. The patient was discharged with a diagnosis of "likely vasovagal" for outpatient follow-up.

"Syncope is the transient loss of consciousness and postural tone, with spontaneous recovery. It accounts for approximately 1% of all emergency department visits and $5.6 billion in healthcare costs annually. In a very small subset of patients, syncope may be a warning sign for serious outcomes or death, but identifying these patients is challenging, as the emergency clinician must distinguish between life-threatening causes and the more common, benign etiologies" (1).

"Syncope is a common reason for ED (Emergency Department)  attendance and it presents a major management challenge with regard to the appropriate workup and disposition. Nearly 50% of patients are admitted, and for many this is unnecessary" (2).      

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is not substantiated.