Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems 
Treatment: Inpatient Hospital. 
The health plan denied inpatient stay. 
The denial is upheld, in whole.

The patient is a female with a history of sinusitis and nephrolithiasis. She presented to the emergency department with a chief complaint of syncope the night prior. Her husband reported that, shortly after eating, she complained of feeling hot and diaphoretic and then lost consciousness two to three times over several minutes. She vomited once and was incontinent of stool. She felt lightheaded and went to an urgent care center. She was sent to the emergency department (ED).
In the ED she denied symptoms. She was alert and oriented. Her blood pressure was 108/72 millimeters of mercury (mmHg) with a heart rate of 91 beats/minute. Her physical exam was unremarkable. Her electrocardiogram and serum troponin level were normal. Chest X-ray was unremarkable.  Head computed tomography (CT) scan showed mild mucosal thickening of the paranasal sinuses and was otherwise unremarkable. The patient was admitted to the hospital. The next day she had no complaints. An echocardiogram showed normal systolic and diastolic left ventricular function. There was no significant valvular pathology. She was seen in consultation by a cardiologist who opined that the etiology for the patient's syncope was likely vasovagal. A neurologist opined that seizures were unlikely. The patient was discharged the following day. Medical necessity for an inpatient admission is at issue.

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

This patient presented with syncope that had occurred the day prior. She was hemodynamically stable, with normal cardiac biomarkers and a normal electrocardiogram. Her physical exam was unremarkable. The literature does not adequately describe which patients will benefit from inpatient hospital admission or care at a lower level status nor has it demonstrated the value of admission in preventing future adverse outcomes. However, certain features have been identified as signifying high risk. These include exertional syncope, known structural heart disease, age greater than (>) 60 years and a family history of sudden cardiac death. This patient had none of these features. Per the 2017 American College of Cardiology (ACC)/American Heart Association (AHA)/Heart Rhythm Society (HRS) Guideline for the Evaluation and Management of Patients With Syncope, inpatient admission is recommended for patients presenting with syncope who have a serious medical condition potentially relevant to the cause of syncope identified during initial evaluation. This patient had no such condition identified. The document further states, "In intermediate-risk patients with an unclear cause of syncope, use of a structured ED observation protocol can be effective in reducing hospital admission. Two small randomized controlled trials suggest that structured ED-based protocols, consisting of time-limited observation and expedited access to cardiac testing/consultation, result in reduced health service use without adverse impact on clinical outcomes when compared with unstructured hospital admission." Thus, based on the information provided, an inpatient level of care was not medically necessary. The patient could have been appropriately treated at a lower level of cares status.