Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems-Arrhythmia/irregular heart rhythm
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

This patient presented to the emergency department complaining of sudden onset of heart racing, chest pain, chills, and diaphoresis. Her medical history was remarkable for hypertension, hypertriglyceridemia, transient ischemic attack, and migraine headache. Her blood pressure was 117/91 millimeters of mercury (mmHg) with a heart rate of 128 beats per (/) minute. Her room air oxygen saturation was 99%. An electrocardiogram showed supraventricular tachycardia at a rate of 181 beats/minute. The patient's serum troponin level was .21 nanograms/milliliter (ng/ml). Chest X-ray showed no acute pathology. The patient's rhythm was converted to sinus with a single bolus of intravenous adenosine. She was admitted to the hospital and oral metoprolol was prescribed. She remained in sinus rhythm and was discharged home later that day. Medical necessity for an inpatient admission is at issue.

The inpatient stay was not medically necessary for this patient.
This patient presented with hemodynamically stable paroxysmal supraventricular tachycardia (PSVT). While there are no established guidelines regarding disposition for patients presenting to the emergency department with PSVT, most authors suggest that, in the absence of serious comorbidities, syncope, or rapid preexcited atrial fibrillation or flutter, hospital admission is not necessary for adults whose PSVT is converted to sinus rhythm without complications. One single-center, retrospective study of patients presenting to emergency department with PSVT found that 71% were discharged home after an average stay of four hours. The 24-hour recurrence rate in those patients was less than 5%. Likewise, data from the National Hospital Ambulatory Medical Care Survey 1993-2003 database revealed a 76% discharge rate for PSVT after evaluation in the emergency department.
While this patient complained of chest pain and had a mild serum troponin elevation, this is common in PSVT, even in the absence of coronary artery disease. It is not recommended that serum troponin levels be measured based on PSVT alone, but only when there is reasonable suspicion of acute coronary insufficiency. The troponin level elevation in this instance did not warrant an inpatient level of care.
In summary, this single episode of hemodynamically stable PSVT that was terminated with intravenous adenosine did not require an inpatient admission.
The Milliman Care Guideline, Supraventricular Arrhythmias (ORG: M-510) was provided for review. Per this document, indications for inpatient admission include hemodynamic instability, heart failure, myocardial ischemia that persists beyond observation level care, altered mental status, persistent tachycardia despite observation level care, underlying condition that necessitates inpatient care, medication toxicity, need for adjustment or initiation of antiarrhythmic drug therapy in a high risk patient, need for urgent cardioversion that cannot be performed on an outpatient basis or under observation level care, repeated implantable defibrillator shocks or need for adjustment beyond the scope of ambulatory or observation care, need for repeat cardioversion, intravenous infusion of anticoagulation, vasoactive or antiarrhythmic medication, other condition requiring inpatient care.
This patient met none of these criteria.