Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Hospital Stay. 
The determination is upheld. 

This is a patient with a history of anemia, heavy menstrual periods, atrial fibrillation on anticoagulants, status/post (s/p) cardiac ablation, stroke with right residual hemiparesis and dysesthesia, neurogenic syncope, and hypotension. She presented to the emergency room with a history of multiple syncopal episodes over the past three days. The vital signs revealed a blood pressure of 95/50 and pulse of 116. (Postural signs were not found in the records.) She was in no acute distress and did not appear to be ill. The physical exam was notable for a large amount of blood with a clot in the vaginal vault. Lab results showed a hemoglobin of 4.2 grams per deciliter (g/dl) and an international normalized ratio (INR) of 1.7. A pelvic ultrasound was remarkable for an enlarged multi-fibroid uterus. A head computed tomography (CT) scan and chest x-ray were non-contributory. Apixaban was held and two units of packed red blood cells were transfused. The blood pressure rose to 107/52. The gynecologist evaluated the patient and found scant bleeding from the cervical os, a 5-millimeter (mm) polyp, and a bulky uterus. Oral medroxyprogesterone and the continuation of transfusions as needed were recommended. 

Upon admission to a monitored bed, the patient was treated with medroxyprogesterone and other oral medications. The hemoglobin was up to 6.7 grams per deciliter (g/L) and an electrocardiogram (EKG) showed atrial flutter with a ventricular rate of 115. Another unit of packed red blood cells was transfused and the hemoglobin rose to 8.0 g/dL. The cardiologist evaluated the patient and noted that she was now in sinus rhythm and no arrhythmias were noted on monitoring. It was concluded that the syncope was most likely due to acute on chronic blood loss and anemia. Resumption of apixaban was recommended if approved by the gynecologist. The remainder of the stay was clinically uneventful and the patient was discharged. 

At issue is the medical necessity of an inpatient stay. 

The requested health service/treatment of inpatient admission was not medically necessary for this patient. Based on a review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or electrocardiogram (EKG) of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. There were no new neurologic signs or symptoms or altered mental status, she was hemodynamically stable, the vaginal bleeding slowed down considerably, the blood pressure rose quickly, and the hemoglobin responded predictably to the blood transfusions that were administered without complications. The services provided, blood transfusions, oral medications, monitoring, consultations, imaging, were not at the acute inpatient level of intensity. Therefore, based on the standard of care, as well as the peer reviewed literature cited and InterQual criteria in the references, the acute inpatient level of care was not medically necessary and the patient could have been managed at a lower level of care.