Diagnosis: Syncope
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is a woman. She presented to the hospital due to loss of consciousness. In the preceding three weeks, she experienced multiple episodes of loss of consciousness. She also noted headaches, episodes of dizziness in which she felt like she was going to faint and leg weakness.

Labs, imaging including CT (computed tomography) head and MRI (magnetic resonance imaging) brain were ordered prior to admission, which did not indicate an acute intracranial process. EKG (electrocardiogram) did not show acute abnormalities Neurology was consulted. There were no focal neurological deficits on the neurological examination. MRI of lumbar spine was done, and did not show an acute process. It was thought that her syncope was due to vasovagal process.

The health plan denied coverage of the inpatient hospital admission as it was not deemed medically necessary. The denial is being appealed.

No, the inpatient hospital admission was not medically necessary.

The inpatient hospital admission was not indicated. The patient had vasovagal syncope. Neurological examination did not show any focal deficits that were moderate to severe, which would have met MCG (Milliman Care Guidelines) guidelines for inpatient admission. Furthermore, there were no seizure-like aspects to the syncope, and so seizure was not thought to be in the differential. Neurology saw her once and signed off.

Therefore, given then above, the inpatient admission was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.

The patient's symptoms were subjective, and there was were no concerning vitals or findings on neurological examination that would have necessitated in admission prior to the studies being done. Workup could have been done on at a lower level of care.