Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope.

Treatment: Inpatient admission.

The insurer denied coverage for: Inpatient admission.

The denial is: Upheld.

This is an adult female patient who presented to the Emergency Department (ED) with complaints of syncope, chest pain, right-sided numbness and weakness. The patient was watching TV and suddenly had right-sided severe chest pain radiating to the right arm and had numbness and weakness in the right upper and lower extremities and was not able to move the right arm or leg. The patient was unresponsive for 5 to 10 minutes and then improved. The motor symptoms improved by the time of presentation. Examination as detailed by the Emergency Department (ED) revealed normal mental status, cranial nerve, sensory and motor functions. In addition to normal constitutional, head, eyes, ears, nose, throat (HEENT), neck, cardiovascular, pulmonary, chest, abdominal and musculoskeletal examinations. A head computed tomography (CT) scan performed on presentation was negative for acute intracranial pathology or trauma/injury. Computed tomography (CT) scan of the chest revealed no acute mediastinal or pleural process. CT scan of the abdomen and pelvis revealed no abdominal pelvic pathology appreciated. CT angiography of the neck was normal. The patient was subsequently admitted to an acute level of care. Workup while hospitalized included a brain magnetic resonance imaging (MRI) that did not reveal any ischemic events. An electroencephalogram (EEG) was negative. The patient had been on chronic Dilantin due to a history of epilepsy and had a subtherapeutic level and received additional Dilantin intravenously (IV) and was continued on the previous dose. Laboratory testing was significant for a slight elevation in alkaline phosphatase. Troponin were negative. 

The patient was found to have regular sinus rhythm with a QR pattern at the V1 lead suggesting right ventricular conduction delay, nonspecific T-wave abnormalities and possible prolonged QT interval. Differential diagnosis was acute coronary syndrome, aneurysm or dissection. The chest pain radiates to the right and was worsened with inspiration. Examination revealed a lateral gaze palsy on the right of the bilateral eyes, difficulty with upward gaze, bilateral mild eye proptosis, sternal tenderness radiating under the right breast, and sensory deficits in the right upper and lower extremities. 

Acute stroke and myocardial infarction required exclusion. Myocardial infarction could be and was ruled out with an electrocardiogram (EKG) and with troponin levels. An acute stroke could be ruled out with computed tomography (CT) and CT angiography and if necessary a brain MRI. As the CT scan and CT angiography were negative, a brain MRI needed to be performed. A brain MRI can be performed in the Emergency Department (ED) or observation setting without the need for acute inpatient hospitalization. Once the patient was ruled out for stroke on MRI, the patient could have been discharged. 

Morris J. (2021), "Syncope is the transient loss of consciousness and postural tone, with spontaneous recovery. It accounts for approximately 1% of all emergency department visits s annually. In a very small subset of patients, syncope may be a warning sign for serious outcomes or death, but identifying these patients is challenging, as the emergency clinician must distinguish between life-threatening causes and the more common, benign etiologies. Low-yield and expensive testing is often performed, even for benign presentations. Much research on syncope is observational, and clinical decision rules frequently perform poorly in validation studies."

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 the inpatient admission is not substantiated.