Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Near syncope

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient is a woman who presented with multiple episodes of near syncope. Her past medical history included coronary artery disease with coronary artery bypass grafting (CABG) x3. Her most recent cardiac catheterization was at another hospital ~1 year earlier in the setting of syncope. That catheterization revealed two patent bypass grafts and one occluded graft, with normal left ventricular ejection fraction (LVEF). There was a non-diagnostic stress test from the day before this admission. Her history of diabetes mellitus, hypertension, and hyperlipidemia were also noted.

A computed tomography (CT) angiogram of the chest was performed in the emergency department (ED), with consolidation in the left lung base consistent with possible pneumonia. Chest x-ray was reassuring. Heart rate in the ED was between 44 and 59 bpm, with normal QTc, normal troponin, and no evidence of heart block or arrhythmia. She had an elevated blood glucose of 158, and mildly elevated white blood cell count of 11.6. She was admitted to telemetry with a diagnosis of symptomatic bradycardia, although with a treatment plan primarily focused on treatment of community-acquired pneumonia (CAP). Her carvedilol was held, presumably to limit bradycardia. An echocardiogram was ordered, although results of this echocardiogram were not included in the submitted documentation, and it is unclear if this test was performed.

IIn the assessment of syncope, she does have some high-risk features in her history, particularly her known coronary artery disease.  However, the coronary artery disease had been thoroughly evaluated recently, and her diabetes was not considered to be a factor in her symptomatology. Her bradycardia was listed as a source of concern, but the fact that this was related to medications reduces her risk level, and suggests that discharge or observation would have been appropriate.  Note that both of these assessments are based on the presence of syncope; her risk was presumably lower with her symptom of near-syncope. 

Additionally, many of her symptoms appeared to be related to community acquired pneumonia. 

The patient did not have chest discomfort, nor any other symptoms that raised suspicion for an acute coronary event; regardless, her workup in this regard was reassuring in relatively short order, with normal troponins and normal electrocardiogram (EKG). Two troponins were adequate to exclude myocardial infarction and to confirm her low risk of adverse events in the absence of chest pain.    The CT angiogram of the chest was reassuring for the absence of pulmonary embolism or other high-risk events.

For these reasons, inpatient admission was not necessary for the patient. Specifically, her bradycardia was mild and attributable to her medications, and her presentation was consistent with community acquired pneumonia, which could have been effectively treated at a lower level of care. Her symptoms resolved within 24 hours with conservative therapy. There was no indication in the submitted documentation to support why additional prolonged hospitalization was medically necessary.

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 inpatient admission is not substantiated.