Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Supraventricular Tachycardia (SVT)

Treatment: Inpatient hospital admission 

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld. 

This patient has a past medical history including thyroid disease s/p (status post) thyroidectomy, head and neck adenocarcinoma, hypertension, diabetes mellitus type 2, obstructive sleep apnea, diffuse idiopathic skeletal hyperostosis (DISH), and lymphedema. She presented to a local medical office with shortness of breath and was found to have wide-complex tachycardia. Emergency medical services (EMS) was contacted, who cardioverted her and transferred her hospital.

She was evaluated in the emergency department (ED). She was in sinus rhythm. Physical exam, vital signs, lab work, and EKG (Electrocardiogram) were largely unremarkable other than a trivial tachycardia at 101 bpm (beats per minute) and right bundle branch block (RBBB). His review of the EMS strips was consistent with supraventricular tachycardia (SVT) with RBBB. The initial troponin was negative. The case was discussed with cardiology who recommended admission to telemetry with serial enzymes. In his note, the doctor indicated that the patient's needs were beyond what the emergency department could offer for managing arrhythmia, and that not admitting her could lead to her death.

An admission history and physical (H&P) was performed. The patient had noted shortness of breath for weeks, although symptoms worsened on the day of admission. There was a stress test 2 months prior to admission that was unremarkable. Physical exam, vital signs, lab work (other than elevated glucose consistent with her known diabetes mellitus), chest x-ray, and history were otherwise unremarkable. The diagnosis made was SVT on a background of incomplete RBBB; the RBBB had been initially noted two months earlier. The plan included overnight observation, cardiology consultation, echocardiography, trending troponin, and managing chronic conditions as at home. If the overnight stay was unremarkable, discharge the following morning was planned. Some right-sided tongue swelling was noted, potentially attributed to Versed received in the ambulance [this had responded to diphenhydramine in the ED].

A cardiology consultation was performed in conjunction. The doctor noted that a similar episode had occurred two months prior to admission, which had prompted a cardiology workup, with the aforementioned negative stress test from that time period, in which the RBBB was initially noted. Patient reported persistent dyspnea at the time of the consultation, while in normal sinus rhythm (NSR). There had never been any chest pain or palpitations. SVT with RBBB was once again diagnosed. Continued telemetry monitoring was recommended.

Full hospital admission was not medically necessary for this patient, as an observation admission (sometimes called "admit as an outpatient") would have been more appropriate for the reasons outlined above. Specifically, the facts that the diagnosis of SVT had been clearly made, and that other lethal conditions had been largely excluded, made a prolonged hospitalization unnecessary. This conclusion was, in fact, clearly stated by the treating physicians in this case. There was reasonable concern, given her persistent dyspnea and recent tongue swelling, that may have warranted overnight observation. However, there is no meaningful indication in the submitted documentation that supports an inpatient hospitalization.

This is consistent with the documentation submitted for review.

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

The insurer's denial of coverage for the full hospital admission is upheld. Medical necessity is not substantiated.