Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Congestive heart failure.
Treatment: Inpatient admission.

The insurer is denied coverage for inpatient admission.  The denial is upheld. 

The patient is a male patient with a past medical history of hypertension (HTN), congestive heart failure, non-ischemic cardiomyopathy, an ejection fraction of 20%, atrial fibrillation (Afib), asthma, and Hodgkin lymphoma who presented to the hospital and underwent placement of an implantable cardioverter defibrillator (ICD). He developed shortness of breath and dizziness and pain at the incision site following the procedure. He was admitted to the inpatient telemetry to receive close monitoring and acute medical management. He had a coronary angiogram which did not show any significant coronary artery disease. His discharge exam done includes temperature 97.7, heart rate 83, respirations 18, blood pressure 148/107 and oxygen saturation 98%. The laboratory data included: sodium 144, potassium 4.6, blood urea nitrogen 20, and creatinine 1.2. His echocardiogram was done, and it showed an ejection fraction of 20%, dilated left atrium and right atrium, moderate concentric left ventricular hypertrophy, severe tricuspid regurgitation, moderate-severe mitral regurgitation, and moderate pulmonary HTN. His chest X-ray done showed the ICD generator with single lead terminating over the region of the right ventricle. The cardiac silhouette was enlarged and globular in shape. The assessment stated that the he had non-ischemic cardiomyopathy, Afib, HTN, asthma, immunocompromising disease, and prior history of lymphoma. He was admitted electively for ICD placement for primary prevention of sudden cardiac (SCD) death. The patient remained stable, tolerated the procedure well without complications and was cleared for discharge home. Evaluation post-insertion of the ICD stated that there was a well-appearing incision without erythema, drainage and no hematoma was noted. He was evaluated on the medical floor and reported improvement in dizziness and fatigue. He reported pain and stiffness around the procedure site. An assessment and plan stated that the patient tolerated the procedure well without complications and was admitted to medicine for monitoring.

The Heart Rhythm Society (HRS) has suggested guidance concerning possible admission for patient having implantation of an automated implantable cardioverter defibrillator. Major conditions that may warrant inpatient admission include, urgent implantation, resynchronization therapy, patients who have a device implantation during hospitalization for another problem, patients who require a lead extraction, patients with complex anticoagulation requirements and patients with uncontrolled comorbidities. The guidelines suggest that patients who do not have the problems listed above could stay overnight and do not require acute hospital admission.

As per Darda et al. (2013), this study's retrospective chart review of 415 consecutive patients who underwent implantable cardioverter defibrillator implantation for prevention of SCD concluded that procedure-related complications after ICD placement are rare. Same-day discharge is safe and feasible following ICD placement for primary prevention of SCD.

This was an elective, scheduled admission and not prompted by any serious events. For these reasons inpatient admission was not medically necessary for this patient. 

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.