Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory Problems
Inpatient Hospital

Diagnosis: Multiple Syncopal Episodes s/p Physical Assault, Post-Concussion Syndrome
Treatment: Inpatient Hospital Services
The insurer denied the inpatient hospital services.
The health plan's determination is upheld.

The patient is a male who initially presented to the emergency department with concerns of dizziness and syncope following an assault. His pertinent medical history included chronic alcoholism, pituitary tumor resection, hyperlipidemia, and hypothyroidism. His initial vital signs revealed a temperature of 97.8 degrees Fahrenheit, a heart rate (HR) of 84, a blood pressure (BP) of 124/70, a respiratory rate (RR) 19, and his peripheral capillary oxygen saturation (SpO2) was 98 percent (%) on room air.
The patient's initial examination documented the patient as alert, oriented, and without focal neurologic deficits. The patient's initial laboratory testing revealed a white blood cell count (WBC) of 8.9, a hemoglobin (Hgb) of 14.7, his platelets (Plt) were 202 and his sodium was 131. His potassium was 3.6, his carbon dioxide (CO2) was 23, his blood urea nitrogen (BUN) was 9, his creatinine was 0.94 and his glucose was 123.
The electrocardiogram (EKG) revealed normal sinus rhythm with T-wave inversion (TWI) and flattening without depressions or elevations. The computed tomography (CT) of the head did not reveal an acute intracranial hemorrhage or territorial infarct. The computed tomography angiography (CTA) of the head and neck did not reveal significant findings. Diaphoresis was observed followed by a syncopal episode while in the emergency department. There were no events were noted on telemetry during this observation.

The patient was placed in the hospital thereafter with an impression of syncope possibly due to vasovagal or post-concussion event. The treatment plan included orthostatic vital signs, an echocardiogram, and Clinical Institute Withdrawal Assessment (CIWA) for chronic alcohol use. Neurology was consulted of whom had an impression of transient loss of consciousness with plans to get an electroencephalogram (EEG) and continue fluid hydration. No patient events were noted overnight and he was hemodynamically stable. There was no significant change in the patient's treatment. There was no recurrence of syncope. The echocardiogram was unremarkable and telemetry was discontinued. The EEG was unremarkable. The patient was discharged with diagnoses of syncope and alcohol abuse.

Runser et al. published guidelines in regards to the evaluation and management of syncope. They suggest that hospital admission be considered if the patient has a clinical history suggestive of arrhythmic syncope, severe anemia, electrolyte abnormalities, electrocardiograph history suggestive of arrhythmic syncope, family history of sudden death, hypotension, severe structural heart disease, congestive heart failure, or coronary artery disease.[1]

The patient had a history of chronic alcoholism and he presented to the emergency department with syncope following an assault. The initial examination found the patient to be hemodynamically stable, alert, oriented, and without focal neurologic deficits. The initial evaluation did not reveal significant laboratory abnormalities, electrocardiographic abnormalities, or CT findings of concern. The treatment plan thereafter included intravenous fluids and additional diagnostic testing. The working diagnosis by all providers was a vasovagal event versus post-concussion event.

The patient did not have hemodynamic instability, an altered mental status, an acute cardiopulmonary event (e.g., central nervous system (CNS) event, pulmonary embolism, arterial dissection, decompensated heart failure) or cardiac disease or finding that indicates necessity of immediate intervention (e.g., outflow tract obstruction, structural abnormality, valvular disease, or cardiac tamponade).