Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness due to severe dehydration; Syncope

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial is upheld.

This patient is a male who presented to the Emergency Department (ED) with a complaint of near syncope.  This event occurred while he was at work in the kitchen.  He suddenly felt lightheaded and felt that he was going to pass out.  He also described tunnel vision and generalized weakness.  He sat down and the Emergency Medical Services (EMS) at his job checked his blood pressure and found that it was 90/50, which prompted them to start intravenous fluids.  He has a past medical history of hypertension, hyperlipidemia, and atrial fibrillation with an ablation done.  The diagnosis listed by his physician included dizziness due to severe dehydration, now treated.  No evidence of any recurrence of atrial fibrillation.  The plan was to continue amiodarone and Eliquis through a specified date and then stop.

Syncope may be classified as reflex, orthostatic, hypotensive, and cardiac.  The commonest cause, irrespective of age, sex, or comorbidity, is vasovagal. (1)  Orthostatic integrity is largely maintained by the interaction between the skeletal muscle pump, neurovascular compensation, neurohumoral effects, and cerebral blood flow regulation.   Subclinical levels of inadequate blood pressure regulation in response to orthostasis have been linked to increased depression and anxiety. (2) A widely accepted guide to the treatment of syncope was published in 2009 as a State-of-the-Art paper. (3) In general, hospital admission is prudent if the suspected underlying problem is associated with high risk of early mortality or injury, the proposed treatment requires in-hospital care, or the affected individual is unable to care for himself or herself.  

Syncope can be caused by serious occult arrhythmias not evident during initial Emergency Department (ED) evaluation.  Investigators sought to develop a risk tool for predicting 30-day arrhythmia or death after ED disposition.  They conducted a multicenter prospective cohort study at six tertiary care EDs and included adults (>=16 years) with syncope.  They collected standardized variables from clinical evaluation and investigations including electrocardiogram and troponin at index presentation.  Adjudicated outcomes included death or arrhythmias including procedural interventions for arrhythmia within 30 days.  They used multivariable logistic regression to derive the prediction model and bootstrapping for interval validation to estimate shrinkage and optimism.  These investigators concluded that the Canadian Syncope Arrhythmia Risk Score can improve patient safety by identification of those at risk for arrhythmias and aid in acute management decisions.  Once validated, the score can identify low-risk patients who will require no further investigations. (6)

This patient was a chef who had been working in a hot kitchen throughout the day of his admission and admitted that he did not drink any water throughout the day.  The patient felt better as his blood pressure quickly responded when he was given intravenous fluids.  It was also noted that his BUN and creatinine had increased and this also returned to normal as fluid therapy was given.  He did not show any of the warning signs that are mentioned in the literature cited by this reviewer which would indicate a poor outcome after a syncopal attack.  Based on the literature cited by this reviewer, the inpatient admission was not medically necessary.  Therefore, denial of coverage for this inpatient admission should be upheld.
The insurer acted reasonably, with sound medical judgment, and in the patient's best interest.

The carrier's denial of coverage for the inpatient admission is upheld.  The medical necessity is not substantiated.