Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope. 
Treatment: Inpatient admission. 
The insurer denied coverage for inpatient admission. 
The denial is upheld. 

The patient presented to the hospital. There was a history of diabetes mellitus, coronary artery disease status post coronary artery bypass surgery, cerebrovascular accident with residual right-sided weakness and speech deficits, hypertension, and hyperlipidemia. The patient was brought in by emergency medical services. The patient had a syncopal episode while at the store. The patient reported sudden onset diaphoresis, weakness, and dizziness. The patient was unsure whether they hit their head. Emergency medical services described that the patient was hypotensive with left facial droop and inability to move the left side. This improved in the emergency department. Vital signs noted blood pressure 132/87, temperature of 35.7 degrees Celsius, pulse of 78, and respirations of 18. The patient appeared mildly diaphoretic. Laboratory testing noted hemoglobin of 10.4, hematocrit of 34.2, glucose of 157, blood urea nitrogen (BUN) of 57, creatinine of 1.89, estimated glomerular filtration rate (EGFR) of 39, carbon dioxide (CO2) of 19.7, and lactate of 2.89. The patient had acute kidney injury that was treated with intravenous hydration. Chest radiograph was negative for acute abnormality. Electrocardiogram showed normal sinus rhythm with minimal voltage criteria for left ventricular hypertrophy which could be normal variant. There was a possible anterior infarct age undetermined.  Neurology was consulted. A computed tomography (CT) neuro perfusion showed hypoperfusion in the right occipital territory with no ischemic core.  Carotid computed tomography angiogram (CTA) showed calcification at the right internal carotid artery origin with underlying mild stenosis of approximately 30 to 40 percent. There was minimal calcification of the left carotid bifurcation. There was bilateral cavernous carotid calcification with underlying bilateral severe stenosis. There was focal calcification and stenosis of the right vertebral artery origin. There was focal calcification and severe stenosis of the distal right vertebral artery. The left vertebral artery was occluded. There was focal calcification and severe stenosis at the basilar artery. There was focal calcification and severe stenosis at the pericallosal portion of the right anterior cerebral artery. There was mild atherosclerotic irregularity of the M1 segment of the right middle artery. There was a suspected syncope episode secondary to transient ischemic attack.  There was a recommendation to monitor telemetry. Magnetic resonance imaging (MRI) revealed no acute infarcts. The patient had syncope with transient left-sided weakness.  There were concerns for syncope with transient ischemic attack versus recrudescent stroke syndrome. The patient was to continue with dual antiplatelet therapy, aspirin, and Plavix. The BUN/creatinine at discharge were 28 and 1.31. The patient was deemed stable for discharge. 

Per the cited references, admission to the hospital may be indicated for patients suspected of transient ischemic attack when there is hemodynamic instability that persist despite appropriate treatment, focal neurological signs recur, findings on brain imaging that requires inpatient care, altered mental status, cardiac arrhythmias of immediate concern, clinically significant cardiac or vascular disorder is identified that requires inpatient care, when there is severe hypertension, when prolonged cardiac telemetry monitoring is needed beyond observation care timeframe, when there is suspected vasculitis, or when parenteral anticoagulation is required. 
Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient hospital admission is not substantiated.