Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infected implantable cardioverter defibrillator (ICD) site. 
Treatment: Full hospital admission. 
The insurer denied coverage for the full hospital admission. 
The denial is upheld. 

This is a female patient with a history of non-ischemic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy (ARVC), non-sustained ventricular tachycardia, hypothyroidism, and hypertension. The patient recently underwent an implantable cardioverter defibrillator (ICD) implantation and presented to the Emergency Department (ED) with a complaint of 4 days of drainage from the ICD insertion site (chest wall) that was described as pink. The patient reported redness in the area and low-grade temperature elevation. The patient's vital signs in the ED were blood pressure 116/67, heart rate 84, respirations 18, temperature 98.2 and oxygen saturation 98%. The patient's electrocardiogram (EKG) showed normal sinus rhythm. On the day of this admission the patient was taken to the Operating Room (OR) and underwent a left chest washout, ICD removal, chest wall exploration with tissue transfer and closure. She was kept overnight for intravenous (IV) antibiotics and had pain management. On the following day, the patient's incision was noted as clean and dry, and she was discharged home with instructions to take oral doxycycline and oral Keflex. 

Observation Units have been developed to improve care of patients who do not have an obvious clinical condition after their ED evaluation. Selected people with chest pain are one of the most prominent groups of such patients. They benefit from Observation Unit care with standardizing timely and accurate risk assessment, implementation of clinical decision rules, and use of accelerated diagnostic protocols. Multiple observation protocols have been developed which have been shown to be safe and deliver effective care. Recognizing the value of an Observation Unit, studies report that over one third of hospitals now have implemented an ED Observation Unit. Emergency Department Observation Units (Obs Units) provide a setting and a mechanism for further care of ED patients. A study described a protocol-driven, type 1, complex 20 bed Obs Unit with 36 different protocols. The study wanted to understand how the different protocols performed and what types of care were provided. This was an institutional review board (IRB)-approved, retrospective chart review study. This study concludes that an Obs Unit can care for a wide variety of patients who require multiple consultations, procedures, and care coordination while maintaining an acceptable length of stay and admission rate.

In this case, this patient presented to the hospital because of an infected ICD site, which caused induration and drainage in the area. The literature review shows that this patient would have been an appropriate candidate for an Observation Unit, rather than full hospital admission, since there was no evidence presented that she had any cardiac injury, but only had an infected ICD site, which required removal of the ICD in addition to antibiotic treatment. The procedure was uncomplicated. The literature review supports that acute hospital admission for this type of patient is not medically necessary and that this patient was an ideal candidate for an Observation Unit. For this reason, the inpatient admission was not medically necessary for this patient. 

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

The carrier's denial of coverage for the full hospital admission should be upheld. The medical necessity is not substantiated.