Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female with history of diabetes mellitus (DM) type II, asthma, panic disorder, and recent right rotator cuff surgery.  She presented to the emergency department (ED) due to possible syncopal episode at home. She was using the restroom, felt dizzy, and passed out. She had two to three seconds of twitching and was confused for one minute after arousing. 

At the hospital, the patient stated right shoulder pain, headache, chest pressure and dyspnea. Vitals included the following: blood pressure (BP) 127/76, pulse (P) 83, respiratory rate (RR) 16, oxygen saturation 95%, and temperature 36.5 degrees Celsius.  Examination revealed the following: alert and oriented times four, no head trauma, right shoulder sling (recent shoulder surgery), tenderness over the right shoulder; the rest of the exam was unremarkable. Laboratory results showed: glucose 163, creatinine 0.64, blood urea nitrogen (BUN) 20.5, sodium 139, potassium 5.0, white blood cell (WBC) 7.58, hemoglobin (Hb) 12.6, platelet 436, and prolactin 50.610. Troponin was negative. 

The electrocardiogram (EKG) showed normal sinus rhythm at 80 beats per minute (BPM). Computed tomography (CT) of the head was unremarkable. Chest x-ray was normal. Right shoulder x-ray did not show acute fracture; surgical anchors are seen post rotator cuff surgery. Electroencephalography (EEG) showed no clear abnormality and no obvious epileptiform discharge noted. Echocardiogram revealed normal left ventricular (LV) size, wall thickness, wall motion and LV systolic function with an estimated left ventricular ejection fraction (LVEF) of 60 to 65%. She had a grossly normal size right ventricle with normal systolic function, trileaflet aortic valve with normal opening, no significant aortic regurgitation, mitral valve leaflets looked normal with normal opening, no significant mitral regurgitation, tricuspid valve looked grossly normal and no significant tricuspid regurgitation. There was insufficient tricuspid regurgitation to estimate pulmonary artery systolic pressure.

The impression was syncope versus seizure. Repeat prolactin level on was 13.72 (within normal range). Further hospital evaluation including brain magnetic resonance image (MRI) was unremarkable. Discharge diagnosis was syncopal episode of unknown etiology, may related to oxycodone (patient took one hour prior). She was discharged home on in stable condition. 

No, the inpatient admission was not medically necessary. 

On presentation to the hospital, the patient was hemodynamically stable. Laboratory studies did not show significant electrolyte imbalance, or anemia requiring transfusion. Troponin was negative, with no evidence to support myocardial infarction. Echocardiogram did not show evidence of acute decompensated heart failure. EKG did not show significant persistent life-threatening arrhythmias that would require inpatient management. CT of the head, and MRI of the brain were unremarkable.  The patient's neurological examination at the hospital was unremarkable; there was no evidence of altered mental status at the hospital. Further, EEG did not show obvious epileptiform discharges; there was no evidence of witnessed seizure in the hospital. Shoulder x-ray did not show acute fracture, requiring inpatient management. 

In view of the foregoing, the proposed treatment is not medically necessary, because the care rendered could have been performed at a lower level of care without adversely affecting the patient's health.