Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Syncope

Treatment:  Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.  The denial was upheld.

This patient is a male who presented to the Emergency Department (ED) complaining of body aches since the previous day.  He claims that his throat only hurts when he swallows.  He also stated that he had to be picked up off the floor at a health center earlier today, but is unsure how he got there.  He says he had a subjective fever at the time.  He denies dizziness, coughing or respiratory symptoms.  His review of systems is negative except for what has been described above.  When he first was examined he was found to be sleeping.  He was described as being in no acute distress and had no abnormalities in his physical exam.  He had no family history of sudden death or syncope.  His initial vital signs recorded on a specified date at 14:05, included: temperature 99.3 F., heart rate 95, blood pressure 136/79, oxygen saturation 98%.  His body mass index (BMI) was 25.4.  The results of initial laboratory studies include white blood cell (WBC) count 20.1 K, hematocrit 37.7, sodium 137, potassium 4.0, glucose 91, blood urea nitrogen (BUN) 14, creatinine 1.0, and initial troponin was within normal limits.  Streptococci group A direct antigen, was negative and nasal swab for influenza A and B, were both negative.  The patient's hospital course described that he requested going home and signing out against medical advice (AMA) multiple times since admission . He agreed to stay overnight and signed out AMA the following morning.
  
A recent widely accepted guide to the treatment of syncope was published in 2009 as a State-of-the-Art paper (1).  In general, hospital admission is prudent if the suspected underlying problem is associated with high risk of early mortality or injury, the proposed treatment requires in-hospital care, or the affected individual is unable to care for himself or herself.  Specific findings supporting in-hospital evaluation include:  Symptoms suggesting acute myocardial infarction (MI), aortic dissection, congestive heart failure (CHF) or pulmonary embolism.  It is clear that none of these conditions were present in this patient.  The low risk group is the largest subgroup of syncope patients and includes mostly vasovagal and orthostatic faints.  This type of syncope is relatively benign in terms of mortality, and most can be discharged (2).

A meta-analysis aimed to establish the role of standardized Emergency Department (ED) observation protocols in the management of syncopal patients as an alternative to ordinary admission.  A systematic electronic literature search was performed to identify randomized controlled trials or observational studies evaluating syncopal patients managed in ED observation units.

This patient came to the hospital after an episode of pre-syncope or near syncope.  He also had an elevated WBC and slight temperature elevation.  There was no description of an electrocardiogram (EKG) showing any arrhythmia or ST segment abnormality.  The workup that he had, including chest x-ray, computer tomogram (CT) of the head and CT of the abdomen, showed no specific abnormalities.

This reviewer has determined that there was insufficient evidence provided that the inpatient hospital admission was medically necessary.  He could have received any care that was necessary at the Observation level of care.  The health plan acted reasonably, with sound medical judgment and in the best interest of the patient. 

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