Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient hospital admission for medical necessity.  The denial was overturned. 

The patient is a male with a past medical history significant for the enlarged left ventricle, heart murmur, and premature ventricular contractions who presented to the emergency department because of an unresponsive state that was witnessed by his wife. The patient's wife noticed that the patient had trouble breathing and she was unable to wake him up. When Emergency Medical Services (EMS) came, the patient was confused and was unable to understand what was going on. 
The review of systems was positive for dizziness but negative for double vision, blurred vision, photophobia, tinnitus, vertigo. The patient denied chest pain, palpitations, irregular heartbeat, cough, sputum production, wheezing. 
When the patient was seen by the admitting physician, he was afebrile. Blood pressure was 93/57, pulse rate was 90 beats per minute (bpm), respiratory rate was 16 breaths/min, and oxygen saturation was 98% on room air.
The patient was awake, alert, and oriented times (x) 3. He was in no acute distress. The head, eyes, ears, neck, throat (HEENT) exam was within normal limits. The neck was supple without lymphadenopathy, masses, jugular vein distention (JVD), or carotid bruits. The rest of the physical exam was unremarkable.
His electrocardiogram (EKG) revealed a normal sinus rhythm, 83 bpm with premature ventricular contraction (PVC)s. The chest x-ray showed no acute abnormalities. A computed tomography (CT) scan of the head was interpreted as normal.
His laboratory evaluation revealed a sodium of 140, potassium was 4.2, chloride was 105, bicarbonate was 24.7, blood urea nitrogen (BUN) was 23, creatinine was 0.9, and glucose was 91. The white blood cell count was 17.3, hemoglobin was 16.4, hematocrit was 47.9, and platelets were 219.
The patient was admitted to the hospital with a diagnosis of an episode of unresponsiveness. Cardiology and neurology services consultations were requested, as well as an electroencephalogram (EEG). It was also indicated that the patient had latent tuberculosis which was treated with Isoniazid and vitamin B6.
During the hospital stay, the patient underwent a magnetic resonance imaging (MRI) scan of the brain and EEG. Both studies were nonrevealing. The telemetry monitoring revealed episodes of non-sustained ventricular tachycardia.
The patient was evaluated by a cardiologist who recommended transfer to a different hospital for an automatic implantable cardioverter defibrillator (AICD) implantation.
At issue is the Inpatient Admission for medical necessity.
The health plan's determination of medical necessity is overturned in whole. 
Yes, the requested health service/treatment of Inpatient Admission was medically necessary for this patient.
This was not a benign syncopal episode. The patient presented with episodes of non-responsiveness, which was related to an arrhythmia of immediate concern in the setting of structural heart disease. He had structural heart disease including dilated left ventricle and reduced ejection fraction. He required prolonged telemetry monitoring that revealed multiple episodes of non-sustained ventricular tachycardia. This prompted consideration of an AICD implantation.  Taking into consideration all these facts, the severity of the patient's condition, and the fact that the patient's episode of non-responsiveness was related to an arrhythmia of immediate concern, the inpatient level of care was justified.
Therefore, the requested health service of Inpatient Admission was medically necessary for this patient.