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. She presented to the hospital via EMS (emergency medical services). She had presented on recommendation from an urgent care center. The patient reported having had a syncopal event two days prior to presentation which resulted in facial trauma. Her medical history was notable for hyperthyroidism. 

The patient had chief complaints of headache, ecchymosis and swelling to her right eye. The patient reported no visual deficits in her right eye. Her EOM (extraocular muscles [movements]) were full. Maxiofacial CT (computed tomography) showed an area of hemorrhagic contusion with vasogenic edema in the right frontal lobe inferiorly. A fracture through the roof of the right sided orbital roof with 1mm (millimeter) of superior displacement was identified. CT (computed tomography) of the cervical spine both returned unremarkable. CT (computed tomography) of the head showed an area of hemorrhagic contusion with vasogenic edema in the right frontal lobe. 

The patient's labs were only notable for a positive troponin level (0.015), but the patient denied chest pain. EKG (electrocardiogram) showed sinus bradycardia. 

The patient was seen by OMFS (oral and maxillofacial surgery) and neurosurgery. She was taken to the surgical ICU (intensive care unit) for monitoring. She was seen by neurosurgery and was noted to have an unremarkable neurological exam. It was determined that there was no indication for acute neurosurgery intervention. The patient was advised that they could follow-up on an outpatient basis if necessary. 

The patient was seen by OMFS (oral and maxillofacial surgery). No acute intervention was deemed necessary. She was advised to follow-up on an outpatient basis. She was prescribed Augmentin, Sudafed and bacitracin. 

The patient was seen by cardiology given the finding of bradycardia and isolated PACs (premature atrial complexes). A TTE (Transthoracic Echocardiogram) was suggested, as well as outpatient follow-up. PM&R (physical medicine and rehabilitation) was also consulted. 

The patient remained in the hospital until she elected to leave AMA (against medical advice). 

Under review is the need for the acute level of care. 

No, the Inpatient admission was not medically necessary. The patient in this case presented to the ED (emergency department) two days following her syncopal incident. The patient at that time was not noted to have any focal neurological deficits on examination. While there was a mild bleed on the CT (computed tomography) scan of the head, there was no evidence of neurological impairment from the bleed on examination. The patient was found to have an arrhythmia, but it was a mild finding and cardiology recommended outpatient follow-up and it was not an issue of concern. There was no need for any other form of acute intervention identified from any of the other specialties either. There was no evidence of significant hemodynamic instability, metabolic instability. The evaluation/care provided was otherwise more appropriate for the observation level of care. 

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.