Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems/Other/Syncope.
Treatment: inpatient admission.
The health plan denied inpatient admission. 
The health plan's determination is upheld.

The patient is a male who initially presented to the emergency department with concerns of syncope. Pertinent history included Bipolar affective disorder and depression. Initial vital signs revealed a heart rate (HR) of 91 beats per minute (bpm), a blood pressure (BP) of 121/69 millimeters of mercury (mmHg), a respiratory rate (RR) of 18/minute, and a peripheral capillary oxygen saturation (SpO2) of 100%. Initial examination documented the patient as alert and oriented without focal neurologic deficits. Initial laboratory testing revealed a white blood cell count (WBC) of 17.8, a hemoglobin of 16.0, platelets of 166, a blood urea nitrogen (BUN) of 23, a creatinine of 1.3, a glucose of 120, a sodium of 140, a potassium of 3.7, a carbon dioxide (CO2) of 26, a total bilirubin of 0.8, an aspartate aminotransferase (AST) of 87, an alanine aminotransferase (ALT) of 209, a creatine kinase (CK) of 259, a lactate of 2.14, and Troponin was negative. The urinalysis was relatively unremarkable. A urine drug screen was positive for tetrahydrocannabinol (THC). An electrocardiogram (EKG) showed normal sinus rhythm without ectopy. The chest radiograph was unremarkable. The computed tomography (CT) of the C-spine was unremarkable. The CT of the head was unremarkable. The patient was placed in the hospital thereafter with an impression of syncope. The treatment plan included telemetry, echocardiogram, orthostatic vital signs, and consultations. There were no new issues. Hemodynamics were stable. Cardiology consulted, did not have an impression of channelopathy or congenital causes, and recommended an echocardiogram. Neurology consulted and recommended a magnetic resonance imaging (MRI) of the brain and an electroencephalogram (EEG), but did not recommend initiating an anti-epileptic drug. The EEG was unremarkable. The patient left against medical advice thereafter.
At issue is the medical necessity for the full hospital admission.

The health plan's determination of medical necessity is upheld, in whole.

No. Based on the clinical documentation provided, evidence-based literature and standards of care, acute inpatient level of care was not indicated as medically necessary for the entire admission. Evaluation and management could have been performed at an alternate level of care.
Runser et al. published guidelines in regard to the evaluation and management of Syncope. They suggest that hospital admission be considered if the patient has a clinical history suggestive of arrhythmic syncope, severe anemia, electrolyte abnormalities, electrocardiograph history suggestive of arrhythmic syncope, family history of sudden death, hypotension, severe structural heart disease, congestive heart failure, or coronary artery disease. [1]
The patient had a history of bipolar schizoaffective disorder who presented after an episode of syncope. Upon arrival, the patient was awake, alert, oriented, hemodynamically stable, and without focal neurologic deficits. A comprehensive evaluation including laboratory testing, EKG, CT imaging, and EEG were essentially unremarkable. No recurrence of syncope was noted during the hospital stay. The treatment plan included additional diagnostic testing. The patient declined further diagnostic testing and left against medical advice.