Diagnosis: Syncope

Treatment: Inpatient hospital admission

The insurer denied coverage for an inpatient hospital admission.

The denial is overturned.

This case involves a male who was seen in the emergency department after experiencing a syncopal episode earlier that day. Documentation indicated EMS (emergency medical services) reported hypotension with systolic pressures in the 70s. He was given a liter of fluids. Upon presentation, he no longer had symptoms. He has had 1 prior syncopal episode when he had COVID-19 (Coronavirus 2019). He had recently received his COVID-19 vaccine within the last month. The physical examination revealed he was tachycardic. It was recommended that he undergo laboratory and diagnostic studies. The documentation indicated he did have an elevated CK (creatinine kinase) at 239, with a troponin of 0.09, and a white blood cell count of 15.3. Additionally, his D-dimer (fibrin degradation fragment) was 0.64 and prothrombin time was 15.5. A CT (computed tomography) scan of the chest revealed atelectatic changes present without focal lobar lung consolidation. There was no evidence of pleural effusion or pneumothorax. A chest x-ray revealed no evidence of acute pulmonary disease. The documentation indicated he was admitted for further treatment. He continued with serial cardiac enzymes and was recommended to undergo a cardiac evaluation. It was recommended he also continue with medication monitoring. He underwent an echocardiogram, which was normal. Additionally, the recommendation was made for imaging of the head which revealed no acute findings.

This inpatient hospital admission is justified.

The Troponin was 0.90, with normal being < (less than) 0.31 in this lab and D-Dimer was 0.64, with normal being < 0.50. The Troponin level being 3 times higher than normal is concerning for an acute cardiac event, which would necessitate an inpatient evaluation.

The health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

The insurer's denial of coverage for the inpatient hospital admission is overturned. Medical necessity is substantiated.