Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

The patient presented to the emergency department (ED) complaining of several days of chest pain and "dizziness" and a witnessed episode of syncope. Her medical history was remarkable for a cardiac arrest due to viral myocarditis and subsequent implantation of an implantable cardioverter defibrillator (ICD). An echocardiogram that had been previously performed showed normal left ventricular systolic function. In the ED, her blood pressure was 112/75 millimeters of mercury (mmHg) with a heart rate of 53 beats/minute. Her physical exam was unremarkable. An electrocardiogram showed sinus rhythm and was similar to prior tracings. Her serum troponin and brain (or B-type) natriuretic peptide (BNP) levels were normal. A chest x-ray and head computed tomography (CT) scan showed no acute pathology. The patient was admitted for further workup and implantable cardioverter defibrillator (ICD) interrogation. The patient reported that her dizziness had improved. Per the progress note, the plan was to interrogate the ICD. The progress note again indicated that the plan was to interrogate the ICD. It also stated that an echocardiogram would be performed and, if unchanged, the patient could be discharged with an implantable loop recorder. ICD interrogation showed no evidence of an arrhythmia. An echocardiogram showed normal left ventricular systolic function. The patient was discharged. An inpatient admission is under review for medical necessity.

Based on the documentation provided an inpatient level of care was not medically necessary.
This patient presented after an episode of syncope. She also reported several days of atypical chest pain. She was hemodynamically stable, with normal cardiac biomarkers and no acute electrocardiographic changes. While she had a history of cardiac arrest due to acute myocarditis, her left ventricular systolic function had returned to normal. Per the 2017 American College of Cardiology (ACC)/American Heart Association (AHA)/Heart Rhythm Society (HRS) Guideline for the Evaluation and Management of Patients With Syncope, inpatient admission is recommended for patients presenting with syncope who have a serious medical condition potentially relevant to the cause of syncope identified during initial evaluation. This patient had no such condition identified. The document further states, "In intermediate-risk patients with an unclear cause of syncope, use of a structured ED observation protocol can be effective in reducing hospital admission. Two small randomized controlled trials suggest that structured ED-based protocols, consisting of time-limited observation and expedited access to cardiac testing/consultation, result in reduced health service use without adverse impact on clinical outcomes when compared with unstructured hospital admission."
Given this patient's history of myocarditis and cardiac arrest, it was appropriate to monitor her until an echocardiogram and ICD interrogation could be performed. However, the records provided do not document any medical reason why this could not have been accomplished within 24 hours of her presentation. Had this been done, the device interrogation would have shown that the patient had not had any serious arrhythmias and, with normal cardiac biomarkers and normal left ventricular systolic function, concern for an acute cardiac event would have been resolved. Then, patient could have been discharged with plans for outpatient follow-up.