Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope.
Treatment: Inpatient hospital stay.
The health plan denied the Inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination. 

The patient presented to the emergency department for evaluation of symptomatic bradycardia and syncope. The patient reported a history of vertigo and was recently diagnosed with chronic lymphocytic leukemia (CLL). She had experienced a syncopal episode while at work.
At that time she became nauseous and diaphoretic and subsequently passed out. She had similar symptoms at the triage in the emergency department, and at that time her heart rate was in the 40's. Following this episode, the patient was feeling somewhat nauseous. She denied fever or chills. When seen by the admitting physician the patient was afebrile. Heart rate was in the 80's, respiratory rate 18 breaths per minute, blood pressure 127/76, oxygen saturation 98% (per cent) on room air. She was awake, alert, and oriented times (x)3, not in acute distress. The head, eyes, ears, neck, throat (HEENT) exam was within normal limits.
The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. Lungs were clear to auscultation without wheezes, rales, or rhonchi. The abdomen was soft, nontender to palpation, with normal bowel sounds, without guarding or rebound. On the neurologic exam, the patient had normal cranial nerves. There were no focal deficits. In the hospital, the patient was seen by a cardiologist who suggested that the patient most likely had vasovagal syncope with no evidence of acute coronary syndrome. During the hospital stay, the patient remained afebrile and hemodynamically stable. There was no mention that she had arrhythmias of immediate concern. She had no recurrent syncopal episodes. Therefore, she was discharged from the hospital.

The inpatient hospital stay was not medically necessary for this patient at the acute inpatient level of care.

There were no clear indications for admission at the acute inpatient level of care since 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. There were no indications for immediate electrophysiologic study or other interventions such as automatic implantable cardioverter defibrillator (AICD) placement.
Based on the telemetry monitoring, there was no evidence that the patient had a high degree of atrioventricular block, bradycardia with sinus pauses, and bursts of supraventricular tachycardia.
Furthermore, there was no evidence that the patient was severely dehydrated. The review of the medical records revealed that the patient remained in stable clinical condition during the entire hospital stay and did not require any treatment or testing that would justify admission at the acute inpatient level of care.
Overall, she remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.
The hospital stay was within the scope of a lower level of care.