Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Presyncope
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with a past medical history of hypertension, diabetes mellitus, an implanted automatic implantable cardioverter-defibrillator (AICD), and stage III chronic kidney disease, who presented to the emergency department after experiencing a near-syncopal episode. She reported feeling lightheaded and subsequently collapsed while getting up to go to the bathroom. During the episode, she hit her left hand and head. The patient denied any preceding or current chest pain, shortness of breath, nausea, vomiting, pain, fever, cough, or headache. She stated that she had never experienced a similar episode before and did not report any vertiginous symptoms such as room spinning. The review of systems was positive only for dizziness and lightheadedness.

An electrocardiogram showed sinus rhythm with a heart rate of 59 beats per minute (bpm) and no signs of acute ischemia. The cardiac device was interrogated to assess its functioning.
The patient received care from a nephrologist during her hospital stay, who diagnosed her with acute kidney injury superimposed on her chronic kidney disease. The nephrologist recommended intravenous fluid infusion, which resulted in a return of her serum creatinine to baseline levels. Additionally, the patient was diagnosed with non-anion gap metabolic acidosis and started on bicarbonate supplements.
Throughout her hospital stay, the patient did not experience further episodes of loss of consciousness, and her kidney function improved. Further evaluation did not reveal any cardiogenic source for her symptoms. Given her stable clinical condition, she was transitioned to outpatient care. At issue is the medical necessity of an inpatient stay.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
There were no clear indications for admission at the acute inpatient level of care since there were no signs of hemodynamic instability or severe or persistent altered mental status. The imaging studies did not reveal evidence of acute stroke, brain mass, or hydrocephalus. There was no indication that the syncopal episode was related to pulmonary embolism, arterial dissection, acute congestive heart failure (CHF) exacerbation, acute blood loss anemia, or acute coronary syndrome. There were no indications for immediate electrophysiological study or other interventions. The interrogation of the automatic implantable cardioverter defibrillator (AICD) did not reveal significant rhythm abnormalities.
Based on the telemetry monitoring, there was no evidence that the patient had a high degree of atrioventricular block, bradycardia with sinus pauses, or bursts of supraventricular tachycardia.
There was no evidence that the patient was severely dehydrated. The dehydration was rather mild. The review of the medical records revealed that the patient remained in stable clinical condition during the entire hospital stay, and did not require any treatment or testing that would justify admission at the acute inpatient level of care.
There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care with subsequent transition to outpatient care, rather than admission to an inpatient level of care. 
Overall, this patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.