Appeal type: Medical necessity
Decision: Upheld



Diagnosis: Bradycardia.
Treatment: Inpatient Hospital Admission.
The insurer denied the inpatient hospital admission. 
The health plan's determination is upheld.

The patient is a male who was admitted to the hospital from a drug rehabilitation program with weakness and dizziness. The patient used heroin four days before this presentation and was at the rehabilitation center, where he developed bradycardia and hypotension with lightheadedness, weakness, and sweating. Upon arrival in the emergency department (ED), his blood pressure was 185/50, heart rate 50, and he had a normal peripheral capillary oxygen saturation (SpO2). After 1 liter of Saline in the ED, his blood pressure was 112/74. He was also given a low dose of Atropine 0.5 milligrams (mg) intravenous (IV) for the bradycardia, which resolved the dizziness, and improved the heart rate. The examination showed obesity, bradycardia, and bilateral lower extremity edema. The rest of the examination was unremarkable.
The laboratory studies showed a normal complete blood count (CBC) with a hemoglobin of 13.6, normal renal function, stable electrolytes, and stable liver function tests (LFT's). The chest x-ray was clear. The electrocardiogram (EKG) showed sinus bradycardia. The medical team ordered a repeat echocardiogram. The previous one was unremarkable. They also checked thyroid function tests and consulted cardiology. The patient was continued on methadone to prevent withdrawal symptoms and psychiatric medications. The medicine attending suspected the bradycardia was a symptomatic side effect of methadone.
The next morning the patient remained in the emergency department, felt improved, and desired to leave the hospital. Cardiology assessed the patient and agreed to obtain an echocardiogram to rule out structural heart disease. The patient left against medical advice later in the morning after being found competent to make his own decisions. The nursing staff describes him as walking steadily, feeling well, without dizziness, chest pain, or shortness of breath.

The inpatient hospital admission was not medically necessary. The documentation describes a man with recent IV drug use history who is undergoing narcotic withdrawals and being treated at a rehabilitation center. He presented to the hospital with dizziness and lightheadedness and was found to be hypotensive and bradycardic. He responded to treatment with IV fluids and low-dose Atropine in the emergency department, with near resolution of the symptoms. Within 24 hours, he was ambulating, completely asymptomatic, with improved heart rates and stable blood pressure. He did not wish to undergo further cardiac work-up and left against medical advice. Clinically, the patient showed an improvement in his condition within 24 hours of presentation. Therefore, an alternate level of care is appropriate for addressing the patient's symptoms. Ideally, an echocardiogram should be completed to evaluate for any changes from his previous echocardiogram, but it can be deferred to the outpatient setting, given the patient's improvement in symptoms. 

The health plan's determination of medical necessity is upheld in whole.