Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/circulatory problems
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital admission 
The denial is upheld in whole

The patient has a past medical history significant for hypertension, sarcoidosis, gastroesophageal reflux disease (GERD), osteoarthritis, and plantar fasciitis who presented to the emergency department due to syncope. Reportedly, the patient passed out on the day of admission. The spouse found the patient sitting on the floor next to the bed. According to the records, the patient had stool incontinence but no nausea, vomiting, palpitations, or swelling. The patient reported a previous syncopal episode a few months back. At that time the patient was admitted to the hospital for 3 days and underwent extensive evaluation. The patient was dehydrated. The 2nd syncopal episode occurred 2 weeks before the day of admission. At that time, the patient was standing and fell back. 

An electrocardiogram (EKG) demonstrated normal sinus rhythm with premature atrial complexes. Otherwise, it was a normal EKG. A chest x-ray revealed a minimal left lower lobe infiltrate and small left pleural effusion. A computed tomography (CT) scan of the head demonstrated no acute process.

The patient was admitted to the hospital with syncope. The admitting physician stated that the patient had no signs of orthostatic hypotension. The initial evaluation that included a CT scan of the head and EKG was negative. The admitting physician stated that the patient was anemic, however, previous H&H was unknown. During the hospital stay the patient underwent telemetry monitoring, which was unremarkable. The echocardiogram demonstrated normal left ventricular ejection fraction.

Carotid duplex ultrasound demonstrated normal carotid arteries on the right side. There was stenosis at the origin of the left internal carotid artery. This was evaluated by a neurologist and they recommended outpatient follow-up. In the hospital, the patient was seen by podiatry service because of plantar fasciitis. During the hospital stay the patient had no further syncopal episodes and was discharged from the hospital in satisfactory clinical condition.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
In order to determine if the patient required admission at the acute inpatient level of care for the evaluation of the syncopal episode, the San Francisco Syncope Rule, which is a risk stratification tool, was referred to.
It predicts risk for serious outcomes at 7 days in patients presenting with syncope or near-syncope. Based on the calculations, this patient received one point.
This means that the patient did not belong to a low-risk group for serious outcomes. Therefore, the patient required a workup in the hospital. At the same time, the review of the medical records clearly demonstrated that there was no evidence of hemodynamic instability or altered mental status. Even though the patient was anemic, there was no evidence of active bleeding. Based on the physical exam, results of the laboratory studies, and diagnostic tests, there was no evidence of stroke, pulmonary embolism, arterial dissection, acute congestive heart failure (CHF) exacerbation, or acute blood loss anemia, which are potentially serious clinical conditions that could lead to a syncopal episode. The admission at a lower level of care was warranted for telemetry monitoring and other diagnostic tests aimed to find the reason for the patient's syncopal episode. The patient remained in overall stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. Neither the severity of the patient's condition nor the complexity of the services provided rose to the level of acute inpatient care.