Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope; Chest pain
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is an adult female. She presented with witnessed syncope and complaints of sharp chest pains (described by the patient as "numbness of left arm"). She had a history of seizure disorder, but was non-compliant with those medications. She had history of TIA, epilepsy, hypertension, and obesity. 

The patient's initial lab results showed elevated CK, hypokalemia, with elevated BP (blood pressure).  EKG normal. Her exam was normal except for elevated BP. She was treated with IVF, potassium replacement, and her Depakote was restarted. 

The patient was admitted to telemetry and placed on seizure precautions. Serial enzymes were negative. Cardiology consult listed differential diagnosis as seizure vs vasovagal. She was discharged with plans for outpatient MRI and EEG. There was no change in her cardiac meds, and she was restarted on anti-seizure therapy. 

Determination of level of care is primarily dependent on the actual care a patient receives, and whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results. It is highlighted in the orders for care. 

In this case, the patient's symptoms were consistent with a vasovagal reaction, i.e. a simple faint. This is not uncommon during the strain of bowel movement and is more common in diabetics. The patient did not lose consciousness, but had consistent diaphoresis and weakness that is common with vasovagal. No evidence of any arrhythmia was noted, nor did the patient have palpitations or near syncope in past. No EP (electrophysiology) consult was obtained (or necessary), no complex work up for syncope was entertained or performed.

The patient's symptoms were very atypical for cardiac etiology and unlikely to be representative of acute coronary syndrome (ACS). Her exam (BP normalized) and cardiac findings were normal. Biomarkers and EKG showed no evidence of acute ischemia. CXR (chest x-ray) was normal. The physicians' treatment did not reflect any serious concern about the patient's cardiac condition.  Orders did not include medical therapy for ACS, such as IV heparin, dual antiplatelet inhibitors, high dose beta blockers or NTG (nitroglycerin).  Progress note suggested discharge.

The letter of appeal was carefully considered but offered no evidence to support a higher level of care. The only care provided was telemetry, which frequently performed in observation and outpatient status. The patient was admitted for monitoring, and the subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care. While there was always a potential for an adverse event (and in this case a low probability), no new event occurred, and no actual treatment was added. The patient was stable throughout her hospital course.

Milliman criteria requirements for syncope inpatient admission were not fulfilled.  One cannot state that there were cardiac arrhythmias of immediate concern that were identified or strongly suspected. That reasoning is not consistent with the opinions of treating physicians or chart notes, thus not a reason to inpatient admits.

None of the medication that was given or tests that were performed required inpatient level of care. All of the testing and therapy that were provided would have been appropriate, safe and guidelines-consistent to be in an outpatient setting. In fact, several of those tests were scheduled to be performed electively as an outpatient. Thus, inpatient level of care was not medically necessary.

The denial explanation was consistent with guidelines and usual community care. Near syncope is clearly an outpatient level of care. Furthermore, it referenced the Circulation article supporting the outpatient work up.