Appeal type: Medical necessity
Decision: Overturned

 
Diagnosis: Sustained Ventricular Tachycardia

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is overturned.

This is the case of a patient that was transferred to NYU hospital for management of sustained ventricular tachycardia (VT) and cardiogenic shock. The patient initially presented with chest pain and acute myocardial infarction.  Following percutaneous intervention to the proximal left anterior descending artery, the patient developed sustained VT requiring cardioversion and amiodarone therapy. The patient was treated with an Impella left ventricular assist device and inotropic therapy and evaluated for emergent cardiac transplant.  Physical examination demonstrated warm extremities and clear lung fields. Electrocardiogram demonstrated normal sinus rhythm with leftward axis and poor R wave progression across the precordial leads.  Echocardiogram demonstrated anteroseptal/apical akinesis and a left ventricular ejection fraction of 15%. Hospital course was complicated by cardiogenic and vasodilatory shock due to gram negative sepsis.  Attempts to wean the Impella device failed due to tachycardia and elevated filling pressures. The patient underwent Heart Mate 3 left ventricular assist device (LVAD) placement. Post operative course was complicated by embolic stroke. The patient subsequently required tracheostomy. Residual deficits required maximal support for activities of daily living. Subsequently, the patient was undergoing physical therapy and awaiting transfer to a rehabilitation facility.  The patient's condition continued to improve with hospital rehabilitation services.  The patient remained hemodynamically stable on intravenous Bumex therapy.  The patient was ultimately transferred to an acute care rehab facility that could accommodate patients with ventricular assist devices.  

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.  This patient presented with acute myocardial infarction and cardiogenic shock requiring advanced cardiac therapy.  The patient's hospital course was complicated by cardiogenic shock, septic shock, and embolic stroke. The patient required extensive rehabilitation and tracheostomy.  The patient was treated with guideline directed medical therapy (1). The patient was also treated for sustained ventricular tachycardia according to American Heart Association (AHA)/American College of Cardiology (ACC) guidelines (2). Acute circulatory support with an Impella device and subsequently a Heartmate 3 left ventricular assist device was necessary and has been well described as the standard of care in patients presenting with acute myocardial infarction and refractory cardiogenic shock (3). In a study focused on trends, mortality and readmissions following left ventricular assist device implantation that included more than 22,000 patients, mean hospital length of stay following LVAD implantation ranged from 33-56 days (4).  Following LVAD implantation, this patient suffered an embolic stroke and required continuing care as well as rehabilitation. In conclusion, continued hospital admission was medically necessary.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for a continued hospital is substantiated.