Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male child with medical history significant for anemia treated with supplemental iron and remote history of asthma. He presented to the ED (emergency department) with two-week history of intermittent heart pounding and racing mainly at rest and one day history of tactile temperature, chest pain, and increased complaints of heart pounding and racing. He was given Tylenol for temperature of 101. He had two episodes of vomiting.

The patient's vital signs included temperature 101.2, heart rate 140, and respiratory rate 18. Examination was significant for no distress, appropriate interactions with family, tachycardia, no murmur or gallop, moist mucous membranes, clear lungs, strong distal pulses, and non-focal neurologic exam. Oxygen saturation was checked and was 98% in room air. Electrocardiogram revealed sinus tachycardia. Laboratory evaluation revealed mild anemia (hemoglobin 10.9) and respiratory viral plan positive for para influenza type IV (type four). CRP (C-reactive protein) was mildly elevated at 0.541. Chest x-ray was unremarkable. He was treated with normal saline bolus and Tylenol resulting in resolution of fever.

The patient remained tachycardic with heart rate 130. Pediatrics was consulted and the decision was made for further evaluation and monitoring for possible myocarditis. Cardiac enzymes were obtained prior to admission and eventually resulted within normal limits. Admission orders included Cardiology consultation and echocardiogram.

Nutrition was consulted because of poor diet at home. Additional orders included thyroid testing, urine drug screen, regular diet, and monitoring vitals. Cardiology recommended outpatient evaluation with echocardiogram and possible Holter monitoring. The patient had no complaints of palpitations overnight and remained hemodynamically stable. There was no evidence of myocarditis or pericarditis. The dietitian made recommendations to address his obesity and poor diet.

The patient was deemed stable for discharge to follow-up with Cardiology and his primary care practitioner, with no sports until Cardiology had given clearance.

No, the Inpatient admission was not medically necessary.
Myocarditis is an inflammatory disease of heart muscle. There are numerous causes, including infection, autoimmune disease, hypersensitivity reactions, and toxins. In developed countries, the cause is usually viral. Enteroviruses are the classic viral pathogen, but other viral agents may cause myocarditis, including adenovirus, parvovirus, Epstein-Barr virus, and cytomegalovirus. Characteristic symptoms on presentation include tachypnea, abdominal pain, vomiting, chest pain, palpitations, and tachycardia. Most patients present with resting tachycardia. Electocardiographic findings include ST-T wave abnormalities and premature contractions. Inflammatory markers are typically elevated. Troponin is a particularly useful marker to trend the disease.

The most common echocardiographic finding is dilated cardiomyopathy with left ventricular dilation and reduced ejection fraction, but other phenotypes may be present. Cardiac MRI (magnetic resonance imaging) is particularly useful because it can be used to assess left ventricular ejection, chamber size, wall thickness, and local areas of edema and fibrosis. Specific MRI (magnetic resonance imaging) diagnostic criteria are available for suspected myocarditis. Complications of myocarditis include arrhythmias, chest pain, myocardial infarction, acute heart failure, and sudden death.

Treatment includes limitation of aerobic activities and management of the primary medical manifestations (eg. treatment of arrhythmias, heart block, decreased left ventricular function). Research has suggested a role for immunosuppressive therapies and antiviral therapies.

This young male child presented to the ED (emergency department) with signs and symptoms consistent with viral infection, with fever and vomiting. However, he also had tachycardia that persisted despite fluids and antipyretics. Evaluation in the ED (emergency department) was unremarkable, with negative chest x-ray, cardiac markers within normal limits, and electrocardiogram with sinus tachycardia but no evidence of cardiac strain or other pathologies. He was admitted for monitoring and possible additional work-up. He remained stable and was discharged the following day, to pursue outpatient cardiology follow-up. Given the potentially serious nature of myocarditis, it was not unreasonable to monitor him in the hospital for a period of time. But he had no objective evidence of myocarditis and he subjectively improved. He did not require acute inpatient admission and could have been managed at a lower level of care. Acute 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.