Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizures
Treatment: Inpatient Hospital Admission
The health plan denied the inpatient hospital admission.
The determination is upheld.

The patient is a female with dementia who was brought in by her family after having a syncopal episode versus seizure after complaining of a headache, passed out, then started shaking and urinated on herself and was unresponsive for 10 minutes on and off. Her vital signs were remarkable for a blood pressure (BP) of 162/55 millimeters of mercury (mmHg). The patient was alert and at her baseline orientation. The physical exam noted jugular vein distention (JVD) and uncooperativeness. Labs were remarkable for a d-dimer of 1006, a hemoglobin of 8.6, an alkaline phosphatase of 166, a pro-brain (or B-type) natriuretic peptide (BNP) of 400, a lactate of 2.1, urinalysis (UA) nitrite positive, large leukocyte esterase, and greater than 50 white blood cells (WBC). A computed tomography (CT) scan of the chest showed linear opacities of unclear significance. An electrocardiogram (EKG) was unremarkable. The patient was treated for a urinary tract infection (UTI) and possible pneumonia with ceftriaxone and azithromycin and was admitted to the hospital. The urine culture grew 10-49,000 Klebsiella. Urology was consulted for findings of staghorn calculus on a CT scan of the abdomen. An echocardiogram was not able to be performed secondary to the patient not cooperating. An electroencephalogram (EEG) was unremarkable. The patient was transitioned to oral antibiotics and discharged home.

At issue is the medical necessity of the inpatient hospital admission. The health plan's determination of medical necessity is upheld in whole. The requested health service/treatment of inpatient hospital admission was not medically necessary.

An alternate level of care would have been appropriate for this patient. Risk assessment is needed to determine which patients present to the emergency room (ER) with syncope have adverse outcomes (Krishnan et al 2020). The data that is available supports the use of scoring systems to determine risk stratification, and those at highest risk need hospitalization (Krishnan et al 2020, Quinn et al 2015). Abnormal EKG, complaint of shortness of breath, hematocrit less than 30 (patient's was 28.6), systolic blood pressure less than 90 mmHg, and a history of congestive heart failure are criteria for admission with syncope (Krishnan et al 2020). Given the patient's hematocrit was less than 30, a work-up was reasonable. She had a negative head CT scan and EEG, and her EKG was unremarkable. The patient's vital signs remained within normal limits. The patient was suspected to have a UTI, and she was started on intravenous (IV) antibiotics (also concurrently for a possibly pneumonia), and when her culture was positive for less than 100,000 of Klebsiellam she was switched to oral antibiotics. Her management was not medically complex, and the patient would not be expected to stay more than 2 midnights on presentation. If she required more complex management or needed to stay more than 2 midnights, she could have subsequently been transitioned to the inpatient level of care. Thus, the patient did not meet criteria for the inpatient level of care as she was not medically complex and would not be expected to stay more than 2 midnights (Centers for Medicare and Medicaid Services [CMS] guidelines).