Appeal type: Medical necessity
Decision: Upheld

The patient is a female with medical history significant for migraine, dysfunctional uterine bleeding following elective termination four months prior with subsequent Nexplanon implantation, and premature atrial contractions (PACs) no longer followed by Cardiology that presented to the emergency department (ED) after having three episodes of syncope with concern for seizure-like activity. With the first episode, she felt unwell, collapsing in the bathroom where she was splashing water on her face. She was incontinent of bladder and bowel at that time. Observers noted that her entire body was shaking. She had two additional episodes of loss of consciousness, striking her head against the sink with the third episode. She complained of headache after, treated with unsuccessfully with aspirin and Tylenol. She did not present to the ED immediately, going the following day because of persistent dizziness with walking.

Vital signs included temperature 36.7, heart rate 93, respiratory rate 16, and blood pressure 116/76. Examination was significant for non-focal neurologic exam, with normal strength and sensation, intact cranial nerves, and no cerebellar signs. X-ray was obtained of the right knee to assess for tibial fracture and was negative. Electrocardiogram revealed normal sinus rhythm with normal axis and intervals, and juvenile T wave inversion. Head computed tomography (CT) was unremarkable, as was chest x-ray. Urine pregnancy testing was negative. CBC and metabolic studies were unremarkable. She was treated with a normal saline bolus and a dose of Toradol. An attempt was made to contact Pediatric Neurology. She was subsequently admitted for further monitoring and evaluation. Admission orders included analgesics as needed for headache, seizure precautions, Ativan as needed for prolonged seizure, Neurology consultation for possible video electroencephalogram (EEG), cardiopulmonary monitoring, vital signs every two hours. Neurology recommended 24-hour video EEG and magnetic resonance imaging (MRI) with and without contrast. Both were completed with no abnormalities noted. Repeat electrocardiogram the day after admission was unremarkable. Because of her history of spotting, she was referred to outpatient Gynecology. She remained stable for the duration of the hospital stay, tolerating regular diet, with no further syncopal episodes or seizure-like activity. She was discharged.

The health plan's determination is upheld.

Syncope and near syncope are not uncommon occurrences in childhood, with up to 35% of children experiencing at least one episode of syncope. Because of the decreased risk of underlying heart disease in the pediatric population, most of these episodes are benign. The yield of diagnostic studies is therefore quite low. The current guidelines recommend increased use of the electrocardiogram to screen for underlying cardiac abnormality because it provide the highest yield, and modified use of imaging studies. "The goal of the evaluation is to identify high-risk patients with underlying heart disease, which may include identifiable genetic abnormalities such as the LQTS [long QT syndrome], Brugada syndrome, or hypertrophic cardiomyopathy." (4) Syncope is an unusual presentation of patients with neurological problems. Such causes should be pursued only if suggested by the history or physical exam. Seizure would be the most common neurologic cause of unconsciousness or unresponsiveness, and EEG would be the diagnostic study of choice, followed by imaging studies to identify structural abnormalities.
This young woman presented with three back-to-back episodes of seizure-like activity, with loss of consciousness, shaking movements, and loss of bowel and bladder control. She presented to the ED because of persistent dizziness. She underwent comprehensive evaluation in the ED without significant findings. She was admitted for further evaluation and Neurology consultation. Additional work-up was also unremarkable, with no identifiable cardiac, neurologic, or metabolic causes for the spells. While it was reasonable and appropriate to pursue more in-depth evaluation in conjunction with continuous monitoring and Neurology consultation, she was overall hemodynamically stable with no notable sequelae. She did not require acute inpatient admission and could have been safely managed at a lower level of care.