Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope
Treatment: Inpatient admission
The proposed treatment, inpatient admission, was not medically necessary.  

The patient is a male, who was seen at the emergency room after a syncopal event.  He reported feeling dizzy with racing heart prior to passing out.  He was unconscious for approximately five minutes.  He denied chest pain, seizure-like activity, or previous similar episodes.

Review of systems was negative for fever, headache, vertigo, dyspnea, orthopnea, paroxysmal nocturnal dyspnea (PND), cough, sputum, hemoptysis, diarrhea, constipation, nausea, and vomiting.  Past medical history included schizophrenia.  Social history revealed the patient lives in a shelter; he is an active cigarette smoker.  Vital signs in the emergency room showed blood pressure 90/64, temperature 98.5F, respiratory rate 16, and oxygen saturation 96%.  Physical examination in the emergency room revealed the patient had a dirty and foul-smelling appearance, dry scaly excoriation in the ankles bilaterally; he had a normal cardiopulmonary examination.  Neurologic/extremities were benign.  

Radiological tests included a chest x-ray which was negative, a computed tomography (CT) of the head which was notable for depressed fracture of the left zygomatic arch, most likely not acute without evidence of skull fracture or intracranial hemorrhage; small area of encephalomalacia in the anterior and medial left frontal lobe.  The patient underwent echocardiogram which showed normal left ventricular systolic function with ejection fraction of 59%; there was no regional wall motion abnormality. Electrocardiogram showed sinus bradycardia with heart rate 57 beats per minutes.  Laboratory studies revealed negative troponin, negative lipase, hemoglobin 13.4, white blood cell (WBC) 3.5, platelets 218, sodium 141, potassium 4.1, creatinine 0.94, glucose 73, potassium 9.0, and magnesium 1.7. 

The admitting diagnosis was syncope; the patient was placed on telemetry. Further hospital evaluation included normal carotid duplex scan.  Telemetry monitoring was unremarkable.  Neurology was consulted and seizure was suspected as possible cause; the patient was added on Keppra with outpatient follow-up with neurology in the clinic.

The patient was deemed medically stable and discharged. 

The patient was admitted for syncopal episode; discharge summary also noted that he received treatment for seizure.  There was no evidence that patient had history of seizures and there was no evidence of documented seizures while in the hospital.  There was no evidence hypotension that persists despite appropriate treatment (e.g., volume repletion, treatment of underlying cause); there is no evidence of orthostatic vital sign changes that persist despite appropriate treatment (e.g., volume repletion). There was no evidence of acute decompensated heart failure, or persistent arrhythmia, brain bleed or acute stroke, acute respiratory failure, sepsis, and active gastrointestinal bleeding, acute coronary syndrome, or heart rhythms that are inherently dangerous (ventricular fibrillation, sustained ventricular tachycardia, resuscitated ventricular fibrillation or cardiac arrest, ventricular escape rhythm). Hospital workup including head CT, echocardiogram, as well as carotid duplex did not show significant pathology that required further intervention.  No cardiovascular intervention was recommended. All the above treatment the patient received could have been performed at a lower level of care without adversely affecting the patient's health. He did not require inpatient level of care.