Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Near Syncopal Episode. 
Treatment: Hospital Admission. 

The insurer denied: Hospital Admission. 
The denial is upheld. 

The patient is a male with a past medical history significant for hypertension and alcohol abuse who presented to the hospital after he collapsed at home. The patient reported that he was urinating in the bathroom when he became dizzy and felt like he was going to pass out. He grabbed onto the sink and did not pass out. When Emergency Medical Services (EMS) arrived the patient's heart rate was in the 180s. He was given Adenosine and Cardizem. When seen by the admitting physician the heart rate was in the 120s. The patient denied any complaints. On initial evaluation in the emergency department, the patient was anemic with a hemoglobin of 8.8. The patient denied any history of bleeding. Computed tomography (CT) angiogram of the chest was performed in the emergency room (ER) and was negative for pulmonary embolism. 

The patient was admitted to the hospital with near syncope. The admitting physician suspected possible gastrointestinal (GI) bleed. At the same time, it was clearly indicated that the patient had no clinical signs of bleeding. The patient received an infusion of packed red blood cells. 

Another clinical diagnosis was supraventricular tachycardia. 
In the hospital, the patient was seen by a gastrointestinal (GI) specialist who recommended esophagogastroduodenoscopy (EGD). The study was performed and demonstrated erosive gastropathy but no active bleeding. The patient was started on iron supplements due to iron deficiency anemia. In the hospital, the patient was seen by a cardiologist who suggested that no further workup was indicated. It was also mentioned that the patient's last drink was 50 days before his presentation, and the patient did not experience any withdrawal symptoms. 

In the hospital, the patient remained in stable clinical condition and was transitioned to outpatient care. The subject under review is the medial necessity for the hospital admission. 

The health plan's determination is upheld. 

The hospital admission was not medically necessary for this patient. 

The patient presented to the hospital with anemia, however, there was no evidence that the anemia was associated with hemodynamic instability, active bleeding, or hemolysis. It was indicated in the notes that the patient had no signs of active bleeding. The anemia was not associated with altered mental status, recurrent syncopal, or near syncopal episodes. According to the records, the patient had one near syncopal episode. There was no evidence of high-risk low platelet count. 

The anemia was not associated with acute renal failure, heart failure, myocardial ischemia, acute peripheral ischemia, or any other signs of symptoms requiring intervention at the acute inpatient level of care. 
Overall, the patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. 
As far as the evaluation and treatment of the near syncopal episode, there were no signs of hemodynamic instability or severe or persistent altered mental status. The imaging studies did not reveal evidence of acute stroke, brain mass, or hydrocephalus. There was no indication that the syncopal episode was related to pulmonary embolism, arterial dissection, acute congestive heart failure (CHF) exacerbation, acute blood loss anemia, or acute coronary syndrome. Even though the patient was anemic, there was no clear evidence of acute blood loss. 

The patient could have been appropriately managed at a lower level of care status.