Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Severe mitral regurgitation; Heart murmur

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial was upheld.

This patient is a male who presented to the hospital complaining of chest pain. He described fever and chest tightness for several days. His maximum temperature prior to arrival was 101.4 F. His symptoms were waxing and waning with no identified actions in the relief or precipitating the symptoms. He has a past surgical history of hernia repair and placement of a tube in his right inner ear. The patient is not a cigarette smoker. His review of systems is positive for fatigue and fever and negative for appetite change, chills and diaphoresis. He does complain of cough but no other symptoms are noted. He did have a sick contact at work with the man who was hospitalized for Legionella disease one week ago. He went to urgent care today and was told that he had a heart murmur and needs to go to the Emergency Department (ED). His family history reveals that his mother has emphysema. The vital signs included; blood pressure 157/78, pulse 86, temperature 98.5 F., respirations 16, oxygen saturation 98% and body mass index (BMI) 33.47.

On physical exam he is described as being in no distress. A murmur is indicated as being heard but not described, his lungs were described as clear. A transesophageal echo (TEE) was done. The heart is normal in size and configuration. Hilar and mediastinal structures are normal and the impression is normal chest radiograph. He was seen by an Infectious Diseases (ID) consultant. An electrocardiogram (EKG) was done and showed normal sinus rhythm at 80 bpm. A note from Infectious Disease (ID) states, that they are currently following the patient off antibiotics, inflammatory markers are negative so far and blood cultures are negative so far. The note states that the patient will be safely discharged after medical needs are met. The patient did have low-grade fevers but now has been afebrile and blood cultures have been negative. No vegetations were seen on TEE. The patient's erythrocyte sedimentation rate (ESR) 16 and the plan is to do an elective cardiac catheterization as an outpatient and then eventual mitral regurgitation (MR) replacement.

The medical investigators assessed all blood cultures obtained from adult inpatients from 1 January 2004 through 31 December 2005 at Robert Wood Johnson University Hospital and Duke University Medical Center. The query was to determine the blood culture efficacy in determining microbial episodes during a 24 hour time frame. The results of this study indicate that two blood cultures in a 24 hour period will detect approximately 90% of bloodstream infections in adults.[1] Positive blood culture is the cornerstone of microbiological diagnosis of IE; three sets of blood cultures detect 96 to 98 percent of bacteremia. [2]

The first Emergency Department (ED) observation units (EDOUs) focused on chest pain and potential acute coronary syndromes. However, most EDOUs now cover multiple other conditions that lend themselves to protocolized, aggressive diagnostic and therapeutic regimens. In this article, the authors discuss the management of four cardiovascular conditions that have been successfully deployed in EDOUs around the country. (5)

The literature that this reviewer has cited shows that he had an appropriate workup to rule out a serious infection such as bacterial endocarditis. He had an appropriate number of blood cultures and was not put on antibiotics. This could have all been accomplished for the patient in an observation unit. Based on these references this reviewer agrees with the insurer's determination that the patient's in-hospital admission was not medically necessary.

Therefore, denial of coverage for the inpatient admission was appropriate. The health plan acted reasonably and with sound medical judgment in the best interest of the patient. 

The carrier's denial of coverage for the inpatient admission is upheld. The medical necessity is not substantiated.