Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope and Headache. 

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld. 

This is a male patient with a past medical history of hypertension, hyperlipidemia, congestive heart failure, and insulin-dependent diabetes.  He presented to the Emergency Department (ED) with recent syncope. The symptoms began about a year prior to presentation when he would have random episodes of passing out. He initially thought his symptoms were related to a lack of sleep but was never evaluated by his primary care physician. A few days prior to presentation the patient went to walk his dog and passed out approximately a block from home. He got up shortly afterwards and returned home where he had a second episode that had lasted much longer. He was diaphoretic during the incident and was shaking all over. He hit the left side of his head and developed a large area of swelling. He has had severe right-sided neck pain and much more frequent episodes of dizziness since then. He had a constant severe headache that felt like pressure or his head was about to explode. He had been taking Tylenol around-the-clock without relief. He could no longer tolerate the pain, which prompted him to go to the ED. His associated symptoms included chills, nausea, vomiting, dyspnea on exertion, vision changes, speech changes, vertigo, hearing changes, photophobia, phonophobia, unsteady gait, and bilateral leg weakness.  

He denied fever, chest pain, swallowing difficulties, numbness, tingling, arm weakness, dysuria, family history of brain aneurysm, and recent travel/hospitalization or other symptoms. His symptoms were concerning for intracranial hemorrhage (ICH) versus posterior circulation cerebrovascular accident (CVA) versus syncope versus concussion.  He was admitted to the hospital for syncope. Magnetic Resonance Imaging (MRI) of the head and electroencephalogram (EEG) were normal. The patient's chest x-ray was normal. The cardiologist recommended placement of an implantable loop recorder. The patient underwent an implant of a loop recorder for the diagnosis of syncope. The device had a low battery. This was explanted and a device with a good battery was implanted and the device was interrogated. The patient complained of chest pain after the procedure and an electrocardiogram (EKG) was performed. The patient had reported some pain and numbness of the left arm, which improved over time. Neurology was consulted and did not recommend any further treatment. Nephrology was consulted for acute kidney injury (AKI) versus chronic kidney disease (CKD). The patient was stabilized and cleared for discharge.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. Services provided, including specialty consultation and diagnostic testing could have been performed in the ED setting and at an observation level of care. Care provided did not warrant an inpatient admission. 

Diagnostic testing including EKG, Carotid Doppler, Computed Tomography (CT), MRI of the brain, and EEG were all within normal limits. Cardiology was consulted and underwent an implant of a loop recorder for evaluation of syncope. Services provided, including specialty consultation and diagnostic testing could have been performed in the ED setting and at an observation level of care. Care provided did not warrant inpatient admission. Therefore, the inpatient hospital admission was not medically necessary for this patient.

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