Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient presented to the emergency department (ED) via Emergency Medical Services (EMS) complaining of chest pain, dyspnea, orthopnea, palpitations and nausea. His medical history was remarkable for diabetes, hypertension, repaired aortic dissection, heart failure with a left ventricular ejection fraction of 40-45% and supraventricular tachycardia. He was noncompliant with his prescribed medical regimen. EMS personnel found the patient to be in supraventricular tachycardia (SVT). They administered adenosine, which failed to terminate the supraventricular tachycardia (SVT). In the emergency department (ED), his blood pressure was 155/110 millimeters of mercury (mmHg) with a heart rate of 177 beats/minute. His arterial oxygen saturation was 100% on 6 liters/minute of supplemental oxygen.
His physical exam was remarkable for obesity, clear lungs, a rapid heart rate, and lower extremity edema. An electrocardiogram showed supraventricular tachycardia. A chest x-ray showed no acute pathology. His serum troponin level was normal. His N-terminal probrain (or B-type) natriuretic peptide (BNP) level was 11,000 picograms per milliliter (pg/ml). His serum bicarbonate level was 17 millimoles per liter (mmol/L) with a normal anion gap and normal venous potential hydrogen (pH). His serum creatinine level was 1.32 milligrams per deciliter (mg/dl) (baseline 1.19-1.2 mg/dl). The patient was treated with an intravenous diltiazem bolus which terminated the tachycardia and his symptoms resolved. He had several brief (approximately 5 second) asymptomatic runs of SVT and received an additional diltiazem bolus. He was admitted to the hospital for management of SVT and decompensated heart failure. He was briefly treated with diltiazem infusion and then with oral metoprolol. He received intravenous furosemide for treatment of heart failure.
The patient had no complaints. He was in sinus rhythm. His serum creatinine level was 1.2 mg/dl. His bicarbonate level was 21 mmol/L. A right upper quadrant ultrasound was performed for evaluation of abnormal liver function tests and revealed hepatic steatosis. He declined catheter ablation and was treated with oral amiodarone. He remained in sinus rhythm. He was discharged. The medical necessity for an inpatient admission is at issue.

Based on the documentation provided, an inpatient level of care was not medically necessary.
This patient presented with supraventricular tachycardia and was in mildly decompensated heart failure. He did not have high risk features associated with heart failure such as hypotension, hyponatremia, serum troponin elevation or serum creatinine level greater than (>) 3.0 milligrams per deciliter (mg/dl). While his N-terminal proBNP level was markedly elevated, interpretation of this can be confounded by the presence of supraventricular tachycardia (SVT), which has been associated with increases in natriuretic peptide levels, even in the absence of congestive heart failure. The patient responded well to treatment with furosemide. In heart failure patients, such as this man, without high risk features, studies have shown that observation level care is safe and effective, with similar outcomes, including readmission, repeat emergency department visits and 30 day mortality, when compared to those treated as inpatients. Thus, in this instance, a lower level of care would have been sufficient; an inpatient admission was not medically necessary for management of this patient's heart failure.
Regarding the patient's paroxysmal supraventricular tachycardia (PSVT): This had been previously diagnosed. The rhythm was terminated in the emergency department with intravenous diltiazem. The patient subsequently had brief, asymptomatic runs of SVT but no sustained episodes. While there are no established guidelines regarding disposition for patients presenting to the emergency department with PSVT, most authors suggest that, in the absence of serious comorbidities, syncope, or rapid preexcited atrial fibrillation or flutter, hospital admission is not necessary for adults whose PSVT is converted to sinus rhythm without complications. One single-center, retrospective study of patients presenting to emergency department with PSVT found that 71% were discharged home after an average stay of four hours. The 24-hour recurrence rate in those patients was less than 5%. Likewise, data from the National Hospital Ambulatory Medical Care Survey 1993-2003 database revealed a 76% discharge rate for PSVT after evaluation in the emergency department. An inpatient level of care was not medically necessary; care could have been provided at a lower level.