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202102-134794

2021

Empire Healthchoice Assurance Inc.

Indemnity

Central Nervous System/ Neuromuscular Disorder

Inpatient Hospital

Medical necessity

Upheld

Case Summary

Diagnosis: Central Nervous System/Neuromuscular Disorder.
Treatment: Inpatient Hospital.
The insurer denied inpatient hospital admission.
The denial is upheld.

The patient is a female with a past medical history significant for tobacco use disorder and cholecystectomy who was brought to the emergency department after she had two syncopal episodes. The first episode occurred two days before the presentation, and the second one took place on the day of admission. Each episode lasted a few seconds. It was associated with intermittent dizziness and lightheadedness. When seen by the admitting physician the patient denied orthopnea or paroxysmal nocturnal dyspnea.

The patient was admitted to the telemetry floor. The patient was seen by a neurologist who suggested that electroencephalogram (EEG) can be performed as an outpatient. The neurologist recommended cardiology consultation and follow-up in the office.
The patient was evaluated by a cardiology service who suggested that the patient had a near-syncope. The cardiologist stated that the physical exam and electrocardiogram (EKG) looked benign. The cardiologist recommended smoking cessation and follow-up in the office.
During the hospital stay, the patient remained in satisfactory clinical condition and was discharged from the hospital on the next day after the day of admission.
The subject under review is the medical necessity for the inpatient hospital admission.

The health plan's determination is upheld.

The inpatient hospital admission was not medically necessary for this patient.
In order to determine if the patient required admission at the acute inpatient level of care for the evaluation of the syncopal episode, the San Francisco Syncope Rule, was utilized, which is a risk stratification tool. It predicts risk for serious outcomes at 7 days in patients presenting with syncope or near-syncope. Based on the calculations, this patient received zero points. This means that the patient belonged to a low-risk group for serious outcomes. Therefore, the workup could have been performed at a lower level of care status. In this particular situation, the patient had recurrent near syncopal episodes. Therefore, the admission for monitoring was reasonable, primarily for cardiac monitoring, however this did not require an inpatient admission and could have been completed at a lower level of care status.
Overall, this patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.

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