Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Non-sustained ventricular tachycardia (NSVT) and frequent premature ventricular contractions (PVCs)

Treatment: Inpatient admission

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

This patient is a female with a history of hyperlipidemia, non-sustained ventricular tachycardia (NSVT) and frequent PVCs who presents to the ED with a complaint of intermittent chest pain, which is described as "coldness" for the past six months. The patient states that nothing seems to make it better or worse including exertion. The symptoms seem worse and were associated with shortness of breath, diaphoresis and nausea which prompted her to come to the ED. This symptom lasted approximately two hours and was present even when she arrived at the hospital. She drank some hot water and noticed that her chest pain improved. The patient has been having similar symptoms in the past and each time it lasted less than one minute. This time was reportedly the most severe. She denies fever, chills, nausea, vomiting and abdominal pain. She denies sick contacts and recent travel. The patient had seen her doctor five days prior and was told that the plan was for an ablation procedure, but a time had not been set. Her review of systems was negative except for what has been described above. An ablation procedure was done. The ablation was done for ventricular ectopy originating from the high mid septal RVOT. Following ablation there was no further evidence of ventricular ectopy.

Arrhythmogenic right ventricular cardiomyopathy (ARVC), also known as arrhythmogenic right ventricular dysplasia, is a heritable heart muscle disorder that predominantly affects the right ventricle. ARVC typically becomes clinically apparent between the second and fourth decades of life. Clinically overt disease is preceded by a preclinical phase, which is characterized by minimal or no structural abnormalities ("concealed disease"). Sudden cardiac death may be the first clinical manifestation of the disease. Prior cardiac arrest due to ventricular fibrillation and sustained ventricular tachycardia are the most important predictors of life-threatening arrhythmic events during follow-up. Catheter ablation is a therapeutic option for patients who have episodes of sustained, monomorphic ventricular tachycardia. (1) Arrhythmogenic right ventricular cardiomyopathy, also known as right ventricular dysplasia, is a genetically determined heart muscle disease associated with arrhythmia, heart failure, and sudden death. Autosomal dominant inheritance is typical. Sudden death is often the first manifestation in probands, emphasizing the importance of evaluating asymptomatic relatives for the disease. 

This patient presented to the hospital with a history of non-sustained ventricular tachycardia (NSVT and VPB's). She was now also complaining of chest pain which she describes as a "coldness" which had been present on and off for six months. On the day of this admission her symptoms were worse since she was describing shortness of breath and diaphoresis. She had been seen by an Electrophysiologist and was scheduled for an ablation procedure which had not yet been scheduled. On examination she had frequent premature beats which was thought to be most likely RVOT in origin. The literature cited discusses the differential between RVOT and ARVC, which may be difficult to differentiate on clinical grounds and in the emergency department. Since sudden death is one of the events which may occur and since it may be difficult to make a precise diagnosis, it is not unreasonable to give the patient the protection of hospital admission in a telemetry unit while she is waiting for the ablation procedure to be done. The healthcare plan did not act in the best interest of the patient by denying this admission. 

Based on the above, the medical necessity for the inpatient admission is substantiated.  The insurer's denial is reversed.