Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness
Treatment: Inpatient Admission
The insurer denied the inpatient admission.
The health plan's determination is upheld.

The patient is a female with past medical history of hypertension, atrial fibrillation (A. fib) on Xarelto, chronic kidney disease (CKD), deep vein thrombosis (DVT) and obesity with a body mass index (BMI) 43. The patient presented with a complaint of dizziness, light headedness and generalized weakness for 2 days. She works 2 jobs and has been exerting herself. The patient denies any recent fever chills cough, recent travel or Coronavirus (COVID) exposure. She also denied syncope, headache, changes in vision, chest pain, shortness of breath, any acute urinary symptoms, excessive vaginal bleeding, melena or hematemesis. The patient's exam was benign. Her vital signs showed that she was afebrile, her heart rate was 60, blood pressure 156/98, respiratory rate 19 and her oxygen saturation (SaO2) was 98 percent (%) on room air. Her blood work showed a creatinine level of 1.6 (baseline 1.5), her troponins and brain (or B-type) natriuretic peptide (BNP) were negative. The patient's electrocardiogram (EKG) showed sinus rhythm with no significant interval change. Her chest x-ray was clear. The patient was persistently bradycardic while on the cardiac monitor. The patient reported persistent light headedness on ambulation despite fluid resuscitation. She takes carvedilol 25 milligrams (mg) 3 times daily, Losartan/Hydrochlorothiazide (HCTZ), Atorvastatin and Xarelto at home. She was admitted to telemetry for presyncope and symptomatic bradycardia.

An echocardiogram that showed mild concentric left ventricular hypertrophy (LVH) with a normal ejection fraction (EF), normal right ventricle (RV) size and function, mild mitral regurgitation (MR) and tricuspid regurgitation (TR) along with an interatrial septal aneurysm. A Holter monitor study that was completed showed her heart rate ranging from 54 to 160, with a mean of 78, no ventricular ectopy and she had supraventricular tachycardia (SVT) that occurred 2 times.
She received intravenous (IV) fluids, and her creatinine decreased from 1.6 to 1.3. Her dizziness and weakness resolved. The dizziness and weakness were most likely from orthostatic hypotension as she has been out in the sun on her job during the day, has not had much oral intake and was going to her second job. She was discharged the next day to follow up with her primary care physician (PCP) and cardiologist as an outpatient, with no new changes to her medications.

The patient required an alternate level of care to watch for dehydration, dizziness and for any arrhythmia secondary to the previous history of SVT. She received IV fluids, her vital signs were stable and her exam was benign. She responded to IV fluids and her symptoms resolved.

The requested health service and treatment of an inpatient admission was not medically necessary for the patient. She required an alternate level of care to monitor for dizziness and to assess for arrhythmias. As her symptoms resolved in 24 hours with hydration, no malignant arrhythmias were noted while she was on telemetry and she was discharged. Her vital signs were normal except heart rate (HR) was in the mid 50's, her blood pressure (BP) was elevated and her EKG did not show any arrhythmias or focal deficit. Her previous Holter monitor study has shown SVT and hence she needed telemetry and an alternate level of care to monitor for arrhythmias.
An alternate level of care is indicated for 1 or more of the following:
Severe vertiginous symptoms, such as vomiting or inability to ambulate, unresponsive to emergency department care,
Vital sign abnormality unresponsive to emergency department care,
Cardiac etiology (eg, arrhythmia) suspected, or
Serious neurologic etiology suspected (eg, ischemia, hemorrhage, hydrocephalus).