Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/ Circulatory problems-Other-Syncope.
Treatment: Inpatient Hospital stay.
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

The patient has a history of pulmonary embolism on Eliquis, protein C deficiency, type 2 diabetes, anxiety, and recurrent syncopal events who presented to the emergency department (ED) for rectal bleeding and a syncopal fall resulting in a head strike and loss of consciousness for about 2-3 minutes (per the history and physical (H&P) note) earlier that day. In the ED, his stool tested guaiac positive. He had left-sided abdominal pain, but no nausea or vomiting. He has had a history of syncopal episodes over the past seven years and had extensive workups, which were negative, including a colonoscopy that showed non-bleeding internal hemorrhoids. At that time he also had an esophagogastroduodenoscopy (EGD) that showed esophagitis and he was taking a proton pump inhibitor (PPI) prior to admission. His initial hemoglobin(Hgb) in the ED was 14.0. liver function tests (LFTs) and lipase were unremarkable. In the ED he was hemodynamically stable and afebrile. He was ordered a 1 Liter fluid bolus along with a computed tomography (CT)scan of the head and c-spine, which were both negative for acute pathology such as a bleed or fracture. Chest x-ray was normal. An electrocardiogram (EKG) showed normal sinus rhythm without ST-T segment(the line on the electrocardiogram that begins with the end of the QRS complex and ends at the beginning of the T wave) changes. He was admitted to the hospital for further evaluation of his gastrointestinal (GI) bleed and syncope. His Eliquis was held, and he was switched to Lovenox. He was given an intravenous (IV) PPI. His Hgb remained stable throughout the admission. There were no arrhythmias noted on telemetry. His orthostatic vital signs were negative. Serial troponins were negative. He was discharged home without event.

Inpatient level of care was not medically necessary for this patient. The patient could have been admitted at a lower level of care. The patient did not meet Milliman Care Guidelines (MCG) criteria for inpatient admission for syncope as he did not have hemodynamic instability, severe or persistent altered mental status, anemia secondary to GI bleeding, or any other relevant underlying diagnosis. 
His CT head and c-spine were negative for acute pathology. He required telemetry and serial troponins to rule out arrhythmia or other cardiac pathology, but this could have been done at the lower level of care. As for his suspected GI bleed, the patient was not anemic and did not require a blood transfusion. He was hemodynamically stable and had an intensive workup for GI bleeding the month prior that returned negative. No repeat procedure was planned or performed during this hospitalization. He needed observation while his anti-coagulant was changed to Lovenox, and his hemoglobin was repeated to ensure stability. This could have been done at a lower level of care. He met MCG criteria for lower level care as his stay was expected to be short term and diagnostic evaluation was required for his syncope to rule out myocardial infarction (MI) or arrhythmia.