Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Recurrent Syncope.
Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is upheld.

This case involves a patient who presented to the emergency department via ambulance with complaints of lightheadedness with a loss of consciousness.  The documentation indicated he does have a past history that includes hypertension in addition to diabetes, pancreatitis, and alcohol abuse.  He also complained of episodes of nausea and vomiting.  The physical examination revealed blood pressure (BP) of 250/108, pain, and a pulse of 61.  Oxygen saturation was 100% (percent).  The recommendation was made from laboratory and diagnostic studies.  The documentation indicated during the physical examination noted he had an additional episode of syncope for 15 seconds; however he eventually was responsive to tactile stimuli.  Exam in the emergency department (ED) showed no focal neuro deficit.  The patient was alert and oriented to person, place and time with normal gait.  The documentation detailed that a CT (computed tomography) angiogram was performed, showing complete occlusion of the left internal carotid.  Laboratory studies revealed hyperglycemia - glucose 365, with no anion gap, venous pH (potential of hydrogen) 7.5, HCO3 [bicarbonates] 31 and a creatinine of 2.95.  Urine showed trace ketones.  Troponin was negative.  No neurological intervention was recommended.  Magnetic resonance imaging (MRI) of head showed no evidence of an acute event.  It was recommended that he be admitted for further treatment.  The documentation indicated he was treated with intravenous medications, and he underwent further monitoring to include an electroencephalogram (EEG) in addition to a Holter monitor.  The documentation detailed throughout the stay continued treatment with medications.  His EEG was unremarkable.  The Holter monitor also did not reveal any significant findings.  His glucose was 129, creatinine 2.8.  With the medication treatment, his blood pressure was controlled.  In fact, while in the ED his BP was recorded as 137/82 and at the time of admission his BP was noted as 139/58.  Exam on admission noted no cardiac abnormality; his lungs were clear.  Neurological exam was again non focal with intact cranial nerves.  He was eventually discharged. 

The patient is a male with a past medical history of hypertension, diabetes, pericarditis and alcohol abuse, who presented to the ED with syncope with lightheadedness with loss of consciousness.  His blood pressure was elevated but improved while still in the ED and was in normal range during the admission exam.  CT angiography demonstrated complete occlusion of the left internal carotid artery.  However, CT and MRI both did not show any acute neurologic event.  Care provided, including diagnostic imaging, medical management including blood pressure management, could have been performed at an observation level of care.  Throughout the entirety of the stay there was no intervention needed or monitoring needed that would necessitate an inpatient admission.  While it is noted above there was evidence of high blood pressure and complete occlusion of the left internal carotid, care provided could have been performed at a lower level.  Therefore, the inpatient admission was not medically necessary.

The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient.

The insurer's denial of coverage for the inpatient admission is upheld.  Medical necessity is not substantiated.