Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

The patient is a male with a past medical history significant for hyperlipidemia who presented to the hospital after he had a near syncopal episode. He was working in his office, and when he stood up, he became severely dizzy and had blurred vision, nausea, cold sweats, and tingling in the fingers of his left hand. He denied losing consciousness, chest pain, or shortness of breath. His symptoms started improving slowly after about 1 minute, but he continued to feel dizzy and nauseous for about an hour. The patient denied similar symptoms in the past.

The patient was admitted to the hospital with near syncopal episodes to rule out non-ST elevation myocardial infarction (NSTEMI). The differential diagnosis included possible ischemic neurological event versus vasovagal syncope versus orthostasis versus benign positional vertigo.
At the time of the initial evaluation, the patient denied fever, chills, nausea, vomiting, headache, changes in vision, chest pain, palpitations, abdominal pain, shortness of breath, productive cough, diarrhea, constipation, urinary changes, focal deficits, or lower extremity edema. The National Institute of Health Stroke Scale (NIHSS) was 0.
Magnetic resonance imaging (MRI) of the brain was ordered to rule out an acute stroke but the patient refused the study due to claustrophobia. A transthoracic echocardiogram was also ordered.
It was also mentioned that the patient had elevated troponin. Therefore, the cardiology service was consulted. According to the cardiologist, there were no signs of acute ischemia. The telemetry monitoring showed no signs of arrhythmia. The patient received treatment with intravenous fluids. The cardiologist stated that the patient was hemodynamically stable. The cardiologist suggested that the near syncopal episode was neurological in nature.
While in the hospital the patient underwent an echocardiogram, which demonstrated normal left ventricular function with normal ejection fraction. There was trace physiologic mitral regurgitation and tricuspid regurgitation.
Throughout the hospitalization, the patient remained asymptomatic. His clinical symptoms did not recur. Therefore, he was transitioned to outpatient care.
The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
There are no indications for admission at the acute inpatient level of care since there were no signs of hemodynamic instability or severe or persistent altered mental status. The imaging studies did not reveal evidence of acute stroke, brain mass, or hydrocephalus.
There was no indication that the near syncopal episode was related to pulmonary embolism, arterial dissection, acute congestive heart failure (CHF) exacerbation, acute blood loss anemia, or acute coronary syndrome. Specifically, acute coronary syndrome was ruled out during this admission.
There were no indications for immediate electrophysiological study or other intervention such as automatic implantable cardioverter defibrillator (AICD) placement.
Based on the telemetry monitoring, there was no evidence that the patient had a high degree of atrioventricular block, bradycardia with sinus pauses, and bursts of supraventricular tachycardia.
Furthermore, there was no evidence that the patient was severely dehydrated.
The review of the medical records revealed that the patient remained in stable clinical condition during the entire hospital stay and did not require any treatment or testing that would justify admission at the acute inpatient level of care.