Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems- Chest pain.
Treatment: Inpatient hospital stay.
The health plan denied the Inpatient hospital stay as not medically necessary. 
The reviewer has overturned in whole the health plan's determination.

This case involves a patient with bronchial asthma, chronic alcohol abuse and dependence, marijuana abuse, hypertension, and peripheral arterial disease with poor compliance with anticoagulation, who presents to the emergency department with chest pain. He was assessed by psychiatry in the emergency department, and plans were established for admission to inpatient psychiatry for detoxification; however, the QTC (time taken for ventricular depolarization and repolarization) was prolonged on the electrocardiogram (EKG), and medical admission was requested. The patient has a prior history of pulmonary embolism, for which he was admitted recently, requiring treatment for 3 months with Eliquis. He reports noncompliance with this medication. A computed tomography angiography (CTA) done in the emergency department failed to demonstrate a new pulmonary embolus. The medical plan included continuous cardiac monitoring, a continuation of metoprolol, serial EKGs and troponins, and an echocardiogram. Of note, the QTC is documented as 489. The patient was placed on an alcohol dependence withdrawal scale. The initial Clinical Institute Withdrawal Assessment (CIWA) score is calculated at 6. He was given thiamine and folic acid. The patient was assessed by cardiology, who delineated prior cardiac testing. They scheduled a nuclear medicine stress test, which showed no evidence of inducible ischemia. A review of serial EKGs showed QTC fluctuated upward to 528 and then down to 457. Potassium was replaced. The medical team consulted hematology for recommendations for anticoagulation. The hematologist recommended resuming Eliquis at 5 milligrams twice daily for 6 months and follow-up in the hematology clinic. The patient was discharged to an inpatient psychiatric facility for detoxification.

The requested health service/treatment of inpatient stay is indicated for the dates in question. This is a complex case, and the patient with polysubstance abuse, poorly compliant with medical therapy, is experiencing angina, and has QTC prolongation. He is at an increased risk of suffering malignant arrhythmias such as torsades de Pointes (a type of polymorphic ventricular tachycardia ), especially in the setting of hypokalemia and hypomagnesemia. The patient is at risk for worsening cardiomyopathy. Telemetry monitoring and EKGs were worrisome, with ST depressions in the inferior lateral leads. The cardiac stress testing did not show inducible ischemia. The patient is also receiving treatment for alcohol withdrawal and had expressed suicidal ideation. Combining these factors makes it challenging to treat this patient under a lower level of care, with the expectation of recovery within a short period of time up to 48 hours. As a result, inpatient hospitalization is indicated due to the need to deploy significant resources to stabilize this patient. Continuous telemetry monitoring, aggressive replacement of electrolytes, monitoring for ischemic changes, and multispecialty support are the clinical factors requiring inpatient hospitalization. As a result, inpatient hospitalization is necessary. Conclusions are based on clinically relevant national guidelines published in peer-reviewed journals.