Diagnosis: Syncope
Treatment is an inpatient admission
The insurer denied coverage for an inpatient admission
The denial is upheld

This adult female with history of hypertension and gastroesophageal reflux disease presented to the emergency room complaining of near syncope after dizziness. Her blood sugar was 126 mg (milligrams)/dL (deciliter) and she reported on and off palpitations. An Electrocardiogram (EKG) showed sinus rhythm, but with flattening T waves (interval on an EKG). The patient claimed that she was in a hot shower when she felt dizzy and fell. She stated that she was held by her son and then passed out or nearly passed out again. She was not taking blood thinners or aspirin on a daily basis. She reported a history of multiple syncopal episodes. Exam findings noted blood pressure 152/91 mmHg (millimeters of mercury) with a pulse of 73 bpm (beats per minute) and a stable temperature at 98.4 degrees F (Fahrenheit). The patient was otherwise normal for cardiovascular and pulmonary assessment. She was alert and oriented to person, place and time, had clear speech, and denied any head or neck trauma. The patient was admitted to telemetry for syncope and prolonged QT (interval on an EKG) waves.

Laboratory testing did not identify any significant abnormalities. A Computed tomography (CT) scan of the head without contrast was unremarkable. A transthoracic echocardiogram (TTE) was conducted with findings showing mild mitral valve thickening and minimal mitral valve regurgitation. Her Ejection Fraction was 56.0% (percent).

The healthcare plan acted reasonably and with sound medical judgment and in the best interest of the patient.

According to the Milliman Care Guidelines, inpatient hospital care is indicated for those individuals who have documented hemodynamic instability, altered mental status that is severe or persistent, has a cardiac disease or finding that indicates necessity of immediate intervention, when a patient has pacemaker or AICD (Automated Implantable Cardioverter Defibrillator) malfunction, has an inheritable cardiovascular condition predisposing them to arrhythmias diagnosed or suspected, when they have severe or persistent dehydration, and syncope causing injury that requires hospitalization. While it was noted that the patient reported dizziness while taking a shower causing her to fall, hit her nose on the wall during the fall, and lose consciousness, the evidence provided for review did not suggest that she did not satisfy the criteria for inpatient admission.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient admission is not substantiated.