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

This is a female patient who was admitted to the hospital after an episode of syncope. The patient reported having had three prior episodes of syncope during the preceding month. Upon admission, her heart rhythm was atrial flutter. Her medical history was remarkable for hypertension, hyperlipidemia, chronic obstructive pulmonary disease (COPD), morbid obesity, left bundle branch block and heart failure with a reduced ejection fraction. Her left ventricular ejection fraction (LVEF) was 30 percent (%) despite six months of guideline directed medical therapy. She was transferred to another institution for implantation of a biventricular implantable cardioverter defibrillator, a transesophageal echocardiogram (TEE) and catheter ablation of her atrial flutter. Upon transfer, an electrocardiogram showed atrial flutter with a ventricular rate of 68 beats/minute. A transesophageal echocardiogram (TEE) showed a moderately reduced LVEF and no evidence of intra-cardiac thrombus. The patient's heart rhythm was electrically cardioverted to sinus. The implantable cardioverter defibrillator (ICD) was implanted without complications. The decision was made to perform the catheter ablation at another time. The patient remained stable overnight and was discharged. At issue is the medical necessity of the inpatient admission.

The inpatient stay was medically necessary. This patient was at considerable risk for major adverse events and required careful and continuous monitoring with the ability to intervene emergently, if needed. This warranted an inpatient admission.
This patient, with a history of heart failure with reduced ejection fraction, presented with recurrent syncope. While the potential causes of syncope are myriad, the presence of underlying cardiovascular disease is predictive of a cardiac etiology with 85 percent (%) to 94% sensitivity and 64% to 83% specificity. In individuals such as this patient, with depressed left ventricular systolic function, syncope is a poor prognostic factor and is often due to potentially lethal ventricular tachyarrhythmias. Thus, implantable cardioverter defibrillator (ICD) therapy for sudden cardiac death prevention is indicated. Given that this patient had experienced four syncopal spells in one month, she was at considerable risk for recurrent episodes and subsequent mortality. Inpatient stay with continuous cardiac monitoring at a facility where implantable cardioverter defibrillator (ICD) implantation could be accomplished was medically necessary.