Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope, Fall.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient presented to the hospital with complaints of an unwitnessed fall. As per the patient, on the day of admission, she woke up at her usual time. She was on the floor for her routine prayer and started to feel "unusual and funny." She stood up without finishing the prayer, and the next thing she remembered was waking up in the hospital. The patient's husband reported that the patient called him and asked to call 911 after she had a fall. The patient denied any previous history of a seizure disorder. There was no history of similar episodes. She was not taking any medications. The review of systems was negative for nausea, vomiting, diarrhea, palpitations, dizziness, lightheadedness, changes in appetite, chest pain, or cough.
When the patient was seen at the emergency department, she was slightly confused and complained of a mild headache. She had a hematoma and laceration on the scalp. The patient was initially seen by trauma surgery. She had a negative computed tomography (CT) scan of the head, and a CT scan of the cervical spine. The electrocardiogram (EKG) demonstrated sinus rhythm, heart rate 59 beats per minute (bpm) with first degree heart block. The patient was admitted to the hospital for evaluation of syncope.
When seen by the admitting physician, her blood pressure was 147/80, pulse rate 64 beats per minute, respiratory rate was 18 breaths/minute, and oxygen saturation 96% on room air.
The patient was awake, alert, and oriented times three. The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. The neck was supple without lymphadenopathy, masses, jugular vein distention (JVD), and carotid bruits. The lungs were clear to auscultation without wheezes, rales, or rhonchi. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. The abdomen was soft, non-tender to palpation, with normal bowel sounds, without guarding or rebound. She was able to move all extremities and had no edema. The neurological exam demonstrated no focal deficits.
Laboratory evaluation revealed that the white blood cell count was 7.1, hemoglobin 13.3, and platelets 233. The sodium was 134, potassium 3.6, chloride 101, bicarbonate 22, blood urea nitrogen (BUN) 23, creatinine 0.8, and glucose 142. Lactic acid was 3.8.
The patient was admitted to the hospital to rule out a seizure versus cardiogenic syncope versus transient ischemic attack (TIA).
Magnetic resonance imaging (MRI) of the brain revealed no acute abnormalities. The patient was ruled out for acute coronary syndrome. She had negative troponins. She had a Holter monitor placed several months ago. It was reported that she had no significant findings. An electroencephalogram (EEG) was also performed, but at the time of discharge, the results were still pending. The stitches that were applied at the time of the initial evaluation were removed before the discharge. Since the patient remained afebrile and hemodynamically stable, she was discharged from the hospital.
At issue is the medical necessity of an inpatient stay.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
There were no signs of hemodynamic instability or severe or persistent altered mental status. The imaging studies did not reveal evidence of acute stroke, brain mass, or hydrocephalus. There was no indication that the possible syncopal episode was related to any other serious conditions such as pulmonary embolism, arterial dissection, acute congestive heart failure (CHF) exacerbation, acute blood loss anemia, or acute coronary syndrome.
There were no indications for immediate electrophysiological study or other intervention such as automatic implantable cardioverter defibrillator (AICD) placement. The Holter monitor could be worn as an outpatient.
Based on the telemetry monitoring, there was no evidence that the patient had a high degree of atrioventricular block, bradycardia with sinus pauses, and bursts of supraventricular tachycardia. The patient only had a first-degree atrioventricular block with minimal bradycardia.
An EEG was a reasonable study to order given the clinical circumstances, however, the study could have been performed at a lower level of care. There was no evidence that the patient was severely dehydrated.
The review of the medical records revealed that the patient remained in stable clinical condition during the entire hospital stay, and did not require any treatment or testing that would justify admission at the acute inpatient level of care.
Overall, she remained in 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. A lower level of care was sufficient to establish a diagnosis and rule out serious reasons for her syncopal episode.