Diagnosis: Syncope
Treatment: Inpatient Hospital Admission
The health plan denied the inpatient hospital admission.
The determination is upheld.

The patient is female who was admitted for syncope with nausea and vomiting in addition to headache. The head imaging was normal. An Echocardiogram showed normal ejection fraction. She was treated with intravenous (IV) fluids and remained stable during this hospitalization.

Per the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, the initial evaluation of syncope includes a careful history and physical examination and an electrocardiogram (ECG). The findings of this initial evaluation can often identify patients who are at low risk for a dangerous etiology (e.g., arrhythmia). Absent other indications for inpatient care, patients with presumptive reflex-mediated syncope (e.g., vasovagal syncope, carotid sinus syndrome, micturition syncope, cough syncope), or syncope due to orthostatic hypotension or dehydration can be managed in the outpatient setting. Patients at intermediate risk for a cardiogenic etiology (arrhythmia, valvular disease) can be further evaluated in an observation care setting, with need for inpatient admission determined by the results of testing and further evaluation (e.g., telemetry)
The patient was hemodynamically stable, with normal oxygenation and negative cultures, did not have significant electrolyte disturbances or change in kidney function. She did not have cardiac arrhythmias and no altered mental status. Therefore, per medical society guidelines, the inpatient admission was not medically necessary and an alternate level of care was more appropriate.

The health plan's determination of medical necessity is upheld in whole.