Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

The patient is a female.  She presented with dizziness, atypical chest pain with radiation to arm, headache and "syncope."  The "syncope" occurred while patient was stressed out, after having seen her psychiatrist and being started on new medicine.  Family issues were also present. 

The patient's initial BP (blood pressure) was 86/67, and she was paced at 70.  She was admitted to telemetry.  She was continued on her home meds.  CT head, echocardiogram and nuclear stress test were performed, and consultations occurred.  She was discharged with primary diagnosis of migraine.

Determination of level of care is primarily dependent on the actual care a patient receives, and whether a higher level of acuity is needed to give this care.  This is best reflected in the presentation, physical exam findings, and laboratory orders and their results.  It is highlighted in the orders for care. 

In this case, the patient's symptoms were consistent with a vasovagal reaction, i.e. a simple faint.  This is not uncommon during the strain of bowel movement (she was on a commode) or with the high stress that she was experiencing.  There was no objective documentation that she lost consciousness, and she had consistent diaphoresis and weakness that is common with vasovagal.  No evidence of any arrhythmia was noted, nor did the patient have palpitations or near syncope in the past.  Her pacemaker was working properly, and thus there was no evidence of arrhythmia.  No EP (electrophysiology) consult was obtained (or necessary).  No complex workup for syncope was entertained or performed.

The patient's symptoms were very atypical and unlikely to be representative of acute coronary syndrome (ACS). Her exam (BP normalized) and cardiac findings were normal.  Biomarkers and EKG (electrocardiogram) showed no evidence of acute ischemia.  Her CXR (chest x-ray) was normal.  CT was negative. LV (left ventricle) function was normal, and nuclear stress test was negative for CAD (coronary artery disease).  The physicians' treatment did not reflect any serious concern about the patient's cardiac condition.   Orders did not include medical therapy for ACS, such as IV heparin, dual antiplatelet inhibitors, high dose beta blockers or NTG (nitroglycerin).  Progress note suggested discharge on migraine medication.

The letter of appeal was carefully considered, but it offered no evidence to support a higher level of care.  The only care provided was telemetry, which is frequently performed in observation and outpatient status.  The patient was admitted for monitoring, and the subsequent tests and therapy did not require an inpatient level of care.  There was no complex care that required inpatient care.  While there was always a potential for an adverse event, one did not happen, and no actual treatment was added.  Milliman criteria requirements for syncope inpatient admission were not fulfilled.  

All testing and therapy that were provided would have been appropriate, safe and guidelines-consistent in an outpatient setting.  Thus, inpatient level of care was not medically necessary.

The denial explanation was consistent with guidelines and usual community care.  It documented the American College of Emergency physicians' position on treatment of how to work up syncope and near syncope as clearly an outpatient level of care.  Furthermore, it referenced the Circulation article supporting the outpatient work up.