Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope, Neck Pain, Postural Dizziness with Vertigo, Vestibular Migraine. 
Treatment: Inpatient hospital admission. 

The insurer denied the inpatient hospital admission. 
The health plan's determination is upheld. 

The patient is a female with a medical history notable for chronic obstructive pulmonary disease (COPD), hyperlipidemia, hypothyroidism, and sciatica who presented with an episode of lightheadedness. 

Upon arrival at the emergency department (ED), the patient was hemodynamically stable, with noted wheezing on examination. Laboratory results were generally within normal limits, except for a low potassium level of 3.4. An electrocardiogram showed normal sinus rhythm with T-wave inversion in anterolateral leads, while troponin levels were normal. Neurology service evaluated the patient and recommended treatment for vestibular migraine using Lamotrigine 25 milligrams (mg) daily for 7 days. In order to rule out central-vestibular and vertebral pathologies, magnetic resonance imaging (MRI) of the brain and cervical spine was conducted. The MRI of the brain yielded unremarkable results for the patient's age, and the MRI of the cervical spine showed no acute findings. Thyroid function tests were within normal range. Additionally, an ear, nose, and throat (ENT) assessment revealed decreased hearing and tinnitus/fullness in the left ear, with Weber's test suggestive of conductive hearing loss. The patient was advised to follow up as an outpatient for further audiology testing. Considering the patient's need for antipsychotic medication, neurology advised discontinuing Lamotrigine and recommended follow-up for further guidance. 

At issue is the medical necessity of an inpatient hospital admission. 
I uphold, in whole, the health plan's determination of medical necessity. 

The inpatient hospital admission was not medically necessary for this patient. 

Based on the patient's history she had a pre-syncopal episode. Based on the current standards of care, admission at the acute inpatient level of care was not indicated since there were no signs of hemodynamic instability or severe or persistent altered mental status. The imaging studies did not reveal evidence of acute stroke, brain mass, or hydrocephalus. There was no indication that the presyncopal episode was related to pulmonary embolism, arterial dissection, acute congestive heart failure (CHF) exacerbation, acute blood loss anemia, or acute coronary syndrome. There were no indications for immediate electrophysiological study or other interventions such as automatic implantable cardioverter defibrillator (AICD) placement. Based on the telemetry monitoring, there was no evidence that the patient had a high degree of atrioventricular block, bradycardia with sinus pauses, or bursts of supraventricular tachycardia. Even though the patient possibly had a migraine, there was no mention of status migrainous, which would be an indication for admission at the acute inpatient level of care. Furthermore, there was no evidence that the patient was severely dehydrated. Even though the patient was wheezing at the time of the presentation, there was no evidence of acute respiratory failure requiring the administration of supplemental oxygen. She possibly had a COPD exacerbation, which was treated with oral corticosteroids and bronchodilators. Furthermore, it was documented by the admitting physician that her lungs were clear to auscultation and the respirations were nonlabored. The review of the medical records revealed that the patient remained in stable clinical condition during the entire hospital stay and did not require any treatment or testing that would justify admission at the acute inpatient level of care.