Diagnosis: Syncope
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient has a past medical history (PMH) of hypothyroidism, vasovagal episodes, and panic attacks who was admitted after being found unresponsive at the bottom of a flight of stairs. Vital signs were initially notable for a blood pressure (BP) in the 60s/50s, triage BP of 72/40, temperature (T) 94.2 degrees Fahrenheit, respirations (R) 29, and oxygen (O2) 95% on 15 liters (L) nonrebreather mask (NRB). The physical exam was notable for lethargy, lacerations on the arms, scalp, and left forehead. Lab work was notable for a troponin of 0.2958, lactate 2.38, white blood cell count (WBC) 15.6.. A computed tomography (CT) scan of the head showed no acute abnormality, a CT scan of the chest showed right lower lobe (RLL) densities, a CT scan of the abdomen/pelvis showed no acute pathology, a transthoracic echocardiogram (TTE) showed a normal ejection fraction (EF). The patient was diagnosed with syncope versus seizures versus arrhythmia and was treated with intravenous fluids (IVF), telemetry, expert consultations, and a significant clinical work-up. The electroencephalogram (EEG) showed spikes and rhythmic bursts and the patient was started on Keppra. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.
The inpatient stay was medically necessary at an acute inpatient level of care.
This patient presented to the Emergency Department after an episode of syncope, likely a fall, new altered mental status, and was started on anti-seizure medications. He required an inpatient level of care as the San Francisco Syncope Rule score was not in the low-risk category, indicating that the patient had an increased risk of cardiac death and was high risk for a serious outcome, especially given the patient's positive troponin, which is suggestive of cardiac ischemia, severe hypotension, and new altered mental status. It is standard of care to admit suspected cardiac syncope to a monitored bed. He had an abnormal EEG, for which neurology started the patient on Keppra, indicating another potentially serious cause of his altered mental status and fall. It would have not been medically appropriate to place this patient in a level of care lower than inpatient given the need for this close monitoring during the work-up and this patient could not have been safely treated at a lower level of care.