Appeal type: Medical necessity
Decision: Upheld

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

This case involves an adult male who presented to the Emergency Department (ED) complaining of hypertension and headache. The patient had a past medical history significant for coronary artery disease, hypertension, cerebrovascular accident, cardiac hypertrophy, fatty liver disease and reportedly "passed out" while standing on a train earlier in the morning. The patient stated that symptoms were accompanied by blurry vision, sweating, and a mild occipital headache graded 4/10 before losing consciousness for approximately one minute. The patient reported no head trauma, jerking movements, tongue biting, or incontinence. When the patient awoke, the patient felt generalized weakness with a tingling sensation throughout the body but was not confused. The patient claimed to have decreased oral intake during the last couple of days and denied chest pain or palpitations preceding the event. The patient also had no recent fever or chills, upper respiratory infection symptoms, nausea/vomiting, abdominal pain, diarrhea, or urinary symptoms. The patient claimed to have decreased exercise tolerance for the past 4 months and reported recent increase in blood pressure medication [nifedipine XL (extended-release) 30 increased to 60 milligrams (mg) twice a day, losartan-hydrochlorothiazide more than a month ago], the patient presented with blood pressure on arrival at 92/59 with a pulse of 68. The report referenced a recent ED visit for knee and headache status post mechanical fall. There were no focal neurodeficits appreciated except for elevated blood pressure. X-ray showed no fracture or dislocation with moderate suprapatellar joint effusion. Computed Tomography of the head, face, and cervical spine were negative for acute fractures, and the patient was provided analgesics, blood pressure medications, and bacitracin. 

Electrocardiogram (ECG) completed showed rate of 69 with normal assessment. The patient had sinus rhythm with elevation of ST segments, flattening and inverted T waves with Left Ventricular Hypertrophy (LVH) and prolonged QTc interval. The patient was subsequently admitted for intravenous hydration and monitoring of creatinine and to monitor for malignant arrhythmias given episode of syncope. The patient was discharged in stable condition. 

According to the Milliman Care Guidelines, the patient did not meet criteria for inpatient care regarding the syncope. The patient was hemodynamically stable and did not have an altered mental status. Additionally, the patient did not have cardiac disease or finding that indicated a necessity of immediate intervention. The patient had no history of pacemaker or Automatic Implantable Cardiac Defibrillator (AICD) malfunction, no inheritable cardiovascular condition, severe persistent dehydration, or syncope causing injury that required hospitalization. The evidence did not support acute level of care, and while the patient claimed to be trying to maintain a low-sodium diet, decreased oral intake was also reported, which likely contributed to dehydration and subsequent dizziness and syncope at work. Rehydration could have been completed on an observation basis and given that evidence did not support any significant cardiovascular abnormalities and no evidence of further injury, the patient did not require inpatient care based upon the provided information. 

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.