Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tachycardia
 
Treatment: Inpatient Hospitalization

The insurer denied the Inpatient Hospitalization. The denial was upheld.                 

This is an elderly male patient who presented to the emergency department (ED) with an elevated heart rate. He stated he routinely checks his heart rate before going to bed and he noted it to be 100. Out of concern he called 911 for help.  He has a medical history of myocardial infarction, congestive heart failure, hypertension, diabetes mellitus, atrial fibrillation, cardiac arrest, automatic implantable cardioverter-defibrillator (AICD). He denied complaints of any chest pain, palpitations, and shortness of breath. He had a chest x-ray that was normal. Interrogation of his pacemaker ICD revealed the presence of mediated tachycardia that was short in duration. There was no evidence of atrial fibrillation, or ventricular tachycardia. 

Observation units have been developed to improve care of patients who do not have an obvious clinical condition after their ED evaluation. A select patient with chest pain is one of the most prominent groups of such patients. They benefit from observation unit care with standardizing timely and accurate risk assessment, implementation of clinical decision rules, and use of accelerated diagnostic protocols. They is a modern structure for cost-effective, high-quality outpatient/in-hospital patient care. (1)

Multiple observation protocols have been developed which have been shown to be safe and deliver effective care. In recognizing the value of an Observation Unit, studies report that over one third of hospitals now have implemented an emergency department (ED) observation unit (2)

Emergency Department Observation Units (Obs Units) provide a setting and a mechanism for further care of Emergency Department (ED) patients. A 2018 study described a protocol-driven, type 1, complex 20 beds Obs Unit with 36 different protocols. They wanted to understand how the different protocols performed and what types of care were provided. This was an IRB-approved, retrospective chart review study. A random 10% of ED patient charts with a "transfer to observation" order were selected monthly from October 2015 through June 2017. This database was designed to identify high and low functioning protocols based on length of stays (LOS) and admission rates. Over 20 months, a total of 984 patients qualified for the study. The average age was 49.5  17.2 years, 57.3% were women, and 32.3% were non-Caucasian. The admission rate was 23.5% with an average LOS in observation of 13.7 h [95% CI 13.3-14.1]. Thirty-day return rate was 16.8% with 5.3% of the patients returning to the ED within the first 72 h. Thirty- six different protocols were used, with the most common being chest pain (13.9%) and general (13.2%). Almost 70% received a consultation from another service, and 7.2% required a procedure while in observation. The procedures included fluoroscopic-guided lumbar punctures, endoscopies, dental extractions, and catheter replacements (nephrostomy, gastrostomy, and biliary tubes). These authors conclude that an Obs Unit can care for a wide variety of patients who require multiple consultations, procedures, and care coordination while maintaining an acceptable length of stay and admission rate. (3)

Based on the above, the medical necessity for the acute inpatient hospitalization is not substantiated. The insurer's denial is upheld.