Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncopal Episode 

Treatment: Inpatient Admission 

The insurer denied the inpatient admission. The denial was upheld. 

This is a female patient who was in her first trimester of pregnancy and presented to the emergency room (ER) with complaints of 3 syncopal episodes. It was reported that while the patient was eating she developed bloating and nausea. She became weak, diaphoretic, light headed and had a syncopal episode. She regained consciousness and had 2 further episodes thereafter. She had a history of fainting spells prior to her pregnancy which were attributed to dehydration. A laboratory work up was performed with normal findings. A urinalysis was performed with positive results for a urinary tract infection; Nitrofurantoin was given for treatment of her urinary tract infection. A chest x-ray and a chest computed tomography were performed with no acute findings. She was consulted by Cardiology and Obstetrics. An electrocardiogram was performed that showed a sinus rhythm with T wave inversions. An echocardiogram was done which was unremarkable. Orthostatic blood pressures were monitored with negative results. 
She received intravenous (IV) fluids. A Doppler of her lower extremities was performed with negative results. The patient was discharged home later the same day. 

According to UpToDate, Approach to the adult patient with syncope in the emergency department: "When evaluating the patient with syncope, the primary responsibility of the emergency clinician is to assess whether a life-threatening cause is present, and to provide appropriate management and disposition. The most important causes to consider are: cardiac syncope, blood loss, pulmonary embolism, and subarachnoid hemorrhage.  Other conditions, such as seizure, stroke, and head injury, do not meet the technical definition of syncope, but should be considered during the initial assessment. A history, physical examination and an electrocardiogram (ECG) should be obtained on all syncope patients." 

Patients with obvious cardiac or neurologic causes of syncope, as well as those with concerning symptoms or signs, should be investigated thoroughly in the ED and likely admitted.  Patients with obvious neurocardiogenic syncope who have returned to baseline and are asymptomatic without injury can be discharged. 

To some degree, clinician judgment determines which symptoms or signs are "concerning," but such findings may include: 1) Syncope accompanied by chest pain or shortness of breath 2) Exertional syncope 3)  Abnormal vital signs
4) Abnormal findings on cardiac, pulmonary, or neurologic examination. 

For well-appearing asymptomatic patients with an unclear cause, clinicians should determine the risk for adverse outcome. Clinicians determine risk on the basis of patient history, examination and electrocardiogram (ECG) findings, and evidence-based guidelines. The presence of any of the following features determines high risk: 1) Abnormal ECG 2) History of structural heart disease or clinical findings suggestive of heart failure 3) Persistently low blood pressure (systolic <90 mmHg) 4) Shortness of breath with event or during evaluation 5) Hematocrit <30 6) Older age and associated comorbidities 7) Family history of sudden cardiac death" 

This patient was stable. She did not have any of the above mentioned "concerning signs." Her workup was completely normal. Note that the patient had been worked up previously for the same condition. 

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

The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.