Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient with a past medical history significant for venous sinus thrombosis being treated with Coumadin, glaucoma, seizures on Vimpat, and bilateral subdural hematoma who presented to the hospital after he had a witnessed fall with a possible loss of consciousness.
Before this episode, the patient was exercising when he started to experience the sensation of discomfort in the epigastrium followed by nausea and generalized weakness. He fell to the ground. Subsequently, the patient recalled feeling foggy after the event, however, remembered a bystander telling him to remain on the ground until Emergency Medical Services (EMS) came. There was no incontinence or generalized tonic-clonic movements. The patient had 2 prior similar episodes within one year. These episodes occurred when he exerted himself. On presentation to the emergency department, the patient had no focal neurologic deficits or cardiopulmonary abnormalities.
Based on the medical records, the blood work was not concerning for acute coronary syndrome. An electrocardiogram (EKG) demonstrated normal sinus rhythm without evidence of heart block or a prolonged QTC interval. A computed tomography (CT) scan of the head was performed and revealed sequela of previously diagnosed venous thrombosis, however, no acute findings.
On the physical exam, the patient was afebrile. His pulse rate was 50 beats per minute (bpm), respiratory rate 18 breaths per minute, blood pressure 127/72, and oxygen saturation 98% on room air.
The patient was in no acute distress. The head, eyes, ears, neck, throat (HEENT) exam was within normal limits. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. The lungs were clear to auscultation without wheezes, rales, or rhonchi. The abdomen was soft, non-tender to palpation, with normal bowel sounds, without guarding or rebound. The rest of the physical exam, including the neurological exam, was normal.
The patient was admitted to the hospital with syncope during exertion, which could be secondary to cardiac etiology versus seizure. Another clinical diagnosis was leukocytosis, which was most likely reactive due to syncope. At the time of admission, the patient was diagnosed with an elevated troponin. Other clinical diagnoses included seizures, macroscopic anemia, and glaucoma.
While on the telemetry floor, the patient remained in normal sinus rhythm. A transthoracic echocardiogram was performed and was interpreted as an unremarkable study. The patient's symptoms improved. During the hospital stay, he remained in stable clinical condition and was discharged from the hospital the next day after admission. At issue is the medical necessity of an inpatient stay.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
Based on the patient's presentation, it does not appear that he had a seizure. The patient most likely had a syncopal or near syncopal episode that was related to exertion, which is a worrisome event necessitating additional intervention including telemetry monitoring and an echocardiogram.
There are no clear indications for admission at the acute inpatient level of care since there were no signs of hemodynamic instability or severe or persistent altered mental status. The imaging studies did not reveal evidence of an acute stroke, brain mass, or hydrocephalus. There was no indication that the syncopal episode was related to a pulmonary embolism, arterial dissection, acute congestive heart failure (CHF) exacerbation, acute blood loss anemia, or acute coronary syndrome. There were no indications for an 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, and bursts of supraventricular tachycardia. There was no evidence that the patient was severely dehydrated.
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.
There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care with subsequent transition to outpatient care, rather than admission to an inpatient level of care. Overall, this patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.