Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Palpitations and Chest Tightness.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female presents with greater than one week of symptoms including palpitations, chest tightness, dizziness, and intermittent dyspnea. The patient has a history of recent COVID(Coronavirus disease) positive test and vaccines performed. 

Electrocardiogram (EKG) showed sinus tachycardia without evidence of ischemia. The patient was hemodynamically stable with normal oxygen levels. D-dimer was elevated without evidence of pulmonary emboli or deep vein thrombosis (DVT).  She was given one dose of Lovenox. Echocardiogram was normal, and she was treated with non-steroidal anti-inflammatory drugs (NSAIDs) for her chronic pain syndrome. 

The patient remained tachycardic but otherwise stable. She received intravenous normal saline (NS). Computed tomography (CT) of the chest was uneventful and she was continued on intravenous fluids and all tests remained stable.  There was a concern for pulmonary embolus (PE) but no evidence of same.  The patient was admitted with "no acute distress". Exam was normal with the exception of the sinus tachycardia.  The final discharge diagnosis was sinus tachycardia secondary to anxiety and panic attack.

No, the proposed inpatient admission was not medically necessary.
Determination of level of care is primarily dependent on the actual care a patient receives and, whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results; and highlighted in the orders for care. 

In this case, the symptoms were atypical and unlikely to be representative of acute coronary syndrome, significant arrhythmias, pulmonary emboli or deep vein thrombosis (DVT). All those conditions were ruled out.  Exam and cardiac findings were normal with the exception of a nonspecific tachycardia. Biomarkers and electrocardiogram (EKG) showed no evidence of acute ischemia. Chest x-ray (CXR) was normal. Echocardiogram showed no wall motion abnormality.

The physicians' treatment did not reflect any serious concern about patient's cardiac condition.  Orders did not include medical therapy for acute coronary syndrome nor anti-arrhythmias.

The letter of appeal was carefully considered but it offered no evidence to support inpatient level of care. The only cardiac care provided was telemetry, frequently performed in a lower level of care. The patient was admitted for monitoring and subsequent tests and therapy did not require an inpatient level of care.

Discharge diagnosis was tachycardia secondary to anxiety and panic attack.

There was no "complex" care that required inpatient level of care. This patient had no evidence of coronary artery disease (CAD). All tests showed absence of ischemia.  While there is always a potential for an adverse event, one did not happen and no actual treatment was added.

Milliman criteria requirements were not fulfilled as there was never any evidence of acute coronary syndrome (ACS) present.

All testing and therapy would be appropriate, safe and guidelines consistent to be in lower level of care. Thus, inpatient level of care was not medically necessary.

The denial explanation was consistent with guidelines and usual community care.