Diagnosis: Syncope.
Treatment: inpatient stay.
The insurer denied inpatient stay.
The health plan's determination is upheld.

The patient is a male with a past medical history significant for seizures, head injury, obstructive sleep apnea, hypertension, diabetes mellitus, and syncope who presented to the hospital after he passed out at work on the day of admission. There were no warning signs, including aura before this happened.
The patient stated that he was behind his desk at work, and the next thing he remembered was being in the emergency department. It was reported that the patient had similar episodes requiring admission.
When the patient was seen by the admitting physician, he denied headache, chest pain, shortness of breath, diaphoresis, dizziness, nausea, vomiting, focal weakness, or numbness. In the emergency department, the patient underwent a computed tomography (CT) scan of the head, which demonstrated no acute intracranial changes.

The inpatient hospital admission is not medically necessary.
There are no clear indications for admission at the acute inpatient level of care, since there were no signs of hemodynamic instability or severe or persistent altered mental status. The imaging studies did not reveal evidence of acute stroke, brain mass, or hydrocephalus. There was no indication that the syncopal episode was related to pulmonary embolism, arterial dissection, acute congestive heart failure (CHF) exacerbation, acute blood loss anemia, or acute coronary syndrome.
There were no indications for immediate electrophysiological study or other intervention such as automatic implantable cardioverter defibrillator (AICD) placement.
Based on the telemetry monitoring and loop recorder interrogation, there was no evidence that the patient had a high degree of atrioventricular block, bradycardia with sinus pauses, and bursts of supraventricular tachycardia. Furthermore, there was no evidence that the patient was severely dehydrated.
The review of the medical records revealed that the patient remained in stable clinical condition during the entire hospital stay, and did not require any treatment or testing that would justify admission at the acute inpatient level of care.