Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Syncope

Treatment: Inpatient hospital admission

The insurer denied coverage for an inpatient hospital admission.

The denial is overturned.

This is a case of a woman who presented to the hospital following an episode of syncope. The patient reported standing up, feeling lightheaded and then losing consciousness. She fell to the floor and hit her head. Past medical history was significant for right hip arthroplasty six days prior to presentation, mechanical mitral valve replacement on warfarin therapy, bilateral diastolic heart failure with pleural effusions, asthma, stroke and depression. Upon EMS (emergency medical services) arrival, the patient was noted to be hypotensive and treated with intravenous fluids. Upon arrival to the hospital, vital signs were stable [Blood pressure (BP) 120/62 mmHg (millimeters of mercury), Pulse 80 bpm (beats per minute)]. Physical examination was significant for a blood-soaked bandage over the right hip. Orthopedic surgery noted that the surgical incision site required no intervention. Decreased breath sounds were noted at both lung bases. Serum blood testing revealed a subtherapeutic INR (international normalized ratio) of 1.8, anemia with a hemoglobin of 9 g/dl (grams per deciliter), and an elevated white blood cell count (17,400), BUN (blood urea nitrogen) 19, CR (creatinine) 1.0. CT (computed tomography) of the head demonstrated no intracranial pathology. The patient was admitted to the hospital for observation and treatment. Repeat CBC (complete blood count) demonstrated worsening anemia with a hemoglobin of 7.8 g/dl. The patient was treated with lovenox and warfarin given subtherapeutic INR. She ultimately signed out against medical advice.

The health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. The patient presented with syncope, hypotension and significant anemia (Hemoglobin 7.8 g/dl). Moreover, the patient had a history of mechanical mitral valve replacement, previous stroke and a subtherapeutic INR. She was status post recent right hip surgery and physical examination revealed a blood-soaked bandage. According to AHA/ACC/HRS (American Heart Association, American College of Cardiology, and the Heart Rhythm Society) guidelines, patients with volume depletion and syncope have a class I indication for fluid resuscitation (Reference 1). This patient's condition was complex due to a history of bilateral pleural effusions and diastolic heart failure. In addition, she was at high risk for cardiac events given her subtherapeutic INR, anemia, and mechanical mitral valve. She required admission to the hospital for further evaluation and treatment (Reference 2). Although patients presenting to the hospital with syncope can often be rapidly discharged, those with cardiac syncope are at high risk for future events that result in increased morbidity and mortality (Reference 1,2). This patient required inpatient hospital admission with careful titration of warfarin, treatment of anemia, and meticulous management of volume status. Admission to the hospital for observation and treatment was medically necessary.

The insurer's denial of coverage for an inpatient hospital admission is overturned. Medical necessity is substantiated.