Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems/Other/Presyncope
Treatment: Inpatient Hospital
The health plan denied the inpatient  stay as not medically necessary. 
The health plan's determination is upheld.

The patient is a female with a past medical history remarkable for diabetes, chronic kidney disease stage V, asthma, and hypertension, who was admitted for evaluation of presyncope. A review of systems was positive for lightheadedness, dizziness, and shortness of breath on exertion.

The patient was afebrile (Temperature of 98.2F. [Fahrenheit]), described as alert, cooperative, and in no acute distress. Her blood pressure was 154/93 millimeters of mercury (mmHg), with a pulse rate of 102 beats per minute (bpm), a respiratory rate of 17/minute, and an oxygen saturation of 100% (percent) on room air. A physical examination was unremarkable for positive clinical findings. The neurologic examination was reported as normal. Laboratory evaluation demonstrated a sodium of 138, a potassium of 4.5, a chloride of 102, a carbon dioxide (CO2) of 16, a blood urea nitrogen (BUN) of 91.7, a creatinine of 9.36, a troponin of 1.01, a white blood cell count (WBC) of 4.7, a hemoglobin of 8.2, a hematocrit of 25.0, and platelets of 230. An electrocardiogram (EKG) revealed normal sinus rhythm and a prolonged corrected QT interval (QTc) of 512. A computed tomography (CT) of the brain was reported as normal. A chest x-ray was negative.

The patient was admitted for presyncope and for rule out of neuro-cardiac causes. She was monitored on telemetry. The patient was evaluated by nephrologist for chronic kidney disease. She was treated with intravenous (IV) fluids. Hemodialysis was discussed as a future plan with the patient. The patient underwent bilateral venous mapping which revealed patent upper extremity veins. The patient was noted to have hypocalcemia of 6.8. She was treated with IV Calcium Gluconate. The patient was also evaluated by endocrinology, and she was treated with Lantus insulin. She had an elevated d-dimer but had no respiratory symptoms and she had a normal oxygen saturations. 
At issue is the medical necessity of the inpatient stay.

The health plan's determination of medical necessity is upheld, in whole.

No, the requested health service/treatment of an inpatient hospital admission was not medically necessary
The patient was admitted for light headedness and dizziness consistent with a diagnosis of pre syncope. In the setting of hemodynamic stability, a normal electrocardiogram (EKG), negative troponins and an unremarkable head computed tomography (CT), the care could have been rendered at an alternate level for rule out of cardiac/neurologic etiology. The documentation does not support inpatient level of care, given the lack of positive clinical findings or focal neurologic findings to warrant a full inpatient admission. Furthermore, the patient had known chronic kidney disease that was stable. The patient did not have urgent or emergent need for inpatient dialysis.
Based on the possible syncope diagnosis, the patient did not meet Milliman Care Guidelines (MCG) criteria for inpatient admission for syncope. She did not have any evidence of cardiac abnormalities. She had no evidence of hemodynamic compromise or neurologic deficits. An alternate level of care would have been appropriate given the low/medium risk (5% 30-day) for serious adverse event related to syncope based on the Canadian Risk Score. An alternate level of care was most appropriate for investigation and further workup.