Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/circulatory problems-Arrhythmia/Irregular Heart rhythm
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay as not medically necessary
The denial was upheld in whole

The patient has long QT syndrome, post implantable cardioverter defibrillator (ICD) placement. The patient also has a history of seizure disorder, cerebrovascular accident (CVA) with left leg weakness, gastroesophageal reflux disease (GERD), post-traumatic stress disorder (PTSD), schizophrenia, and depression. The patient had the CVA last year with residual left sided weakness. The patient was not on blood thinners, and was started on Aspirin.
The patient was seen at an OSH. Her device was interrogated, there were no arrhythmias noted, and  was discharged to home. The symptoms persisted and patient came by ambulance to the emergency department the next day.
The patient presented with palpitations and dyspnea that started the day prior to presentation. Prior to that, there were on and off palpitations, shortness of breath, and lightheadedness.
The patient had reported recurrent atrial fibrillation and ventricular tachycardia, but device interrogation did not reveal any arrhythmia. Of note, the patient recently was admitted to an OSH  and  had a clinical appointment  and was recommended to continue Nadolol.
The vital signs were normal, physical examination was unremarkable, labs were normal,electrocardiogram (ECG) was normal, without any arrhythmia. The patient was admitted to a telemetry bed.
The patient was consulted by cardiology. It was noted that the telemetry revealed signs of sinus tachycardia and heart rate (HR) was over 140 beats per minute (BPM). The patient was recommended to be transferred for further management of tachyarrhythmia, for EP study. The patient was deemed stable for transfer, and was transferred.

The requested health service/treatment of Inpatient Hospital Admission was not medically necessary for this patient. The patient presented with palpitations. The vitals and physical examination were unremarkable. Labs and ECG were normal. The patient had runs of what looked like sinus tachycardia. The patient's overall stable status and episodes of arrhythmia, which were not life threatening and were not associated with hemodynamic compromise, would support a lower level of care, and not inpatient.
An invasive EP study permits the precise diagnosis of the underlying arrhythmia mechanism and localization of the site of origin and provides definitive treatment if coupled with catheter ablation. There are standards that define the equipment and training of personnel for optimal performance of EP study. EP studies involve placement of multielectrode catheters in the heart at Z1 sites in the atria, ventricles, or coronary sinus. Pacing and programmed electrical stimulation may be performed with or without pharmacological provocation. Making a precise and correct diagnosis of the mechanism of SVT is the key to successful outcome, particularly when multiple arrhythmia mechanisms are possible; as such, appropriate diagnostic maneuvers should be performed before proceeding with ablation. By using diagnostic maneuvers during the EP study, the mechanism of SVT can be defined in most cases. Complications of diagnostic EP studies are rare but can be life threatening. This patient was transferred for further management of her tachyarrhythmia, however, could have been treated at a lower level of care prior to the transfer.