Diagnosis: Syncope.
Treatment: Inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission. The denial is upheld.

This is a female patient, who presented to the hospital due to syncope and a presumed fall. The documentation indicated that the patient has a past medical history that includes diabetes. The documentation detailed in the Emergency Department (ED) noted that the patient was mildly amnestic, recalling waking up at 6 a.m., having a cup of coffee, and walking to the gym, but she did not remember what happened after that. The patient was found on side of street. The patient had a laceration to the forehead that required sutures. The patient's glucose was 180, and she was able to move all extremities. She was oriented X3. She was conversing normally, only complaining of sternal chest pain. The patient's examination revealed an abrasion to the lateral left knee with full range of motion. Neurological exam showed no deficits.

As per the documentation, the patient underwent laceration repair while in the ED. The patient's chest x-ray revealed no acute cardiopulmonary process. There was no fracture noted to the pelvis, and the physician detailed that they would likely admit for syncope work-up. A computed tomography (CT) scan of the head revealed no intracranial lesion. There was no skull fracture. There was right frontal and left parietal subcutaneous soft tissue swelling. The patient's CT scan of the spine did not reveal any acute findings. The patient's laboratory studies revealed sodium of 141 with potassium of 4.2. The patient's BUN was 13, and creatinine was 0.8. The patient had a negative troponin. The patient was admitted and given medications. The patient underwent an echocardiogram, which was remarkable for a left ventricular ejection fraction of 65%. The patient's white blood cell (WBC) count on admission was notable at 14.2, which decreased the following day. The patient continued with treatment and monitoring, as well as daily dressing changes. The patient did not have any other significant adverse events during the hospital stay. The patient was discharged with instructions to follow-up given the continued stability.

Based on the review of the medical record, this case involves a patient that presented with probable syncope. There was no evidence of an acute neurologic or cardiac event. Extensive testing and imaging did not reveal any acute pathology that required inpatient admission. The patient could have been observed, and when no acute issues found, discharged to be followed as an outpatient.

The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for a full hospital admission should be upheld. The medical necessity is not substantiated.