Appeal type: Medical necessity
Decision: Upheld

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


This patient presented to the emergency department after a 30 second episode of dyspnea, palpitations, lightheadedness and chest discomfort. His medical history was remarkable for Wolff Parkinson White syndrome, Factor V Leiden deficiency and seizure disorder. His blood pressure was 132/88 millimeters of mercury (mmHg) with a heart rate of 59 beats/minute. His room air oxygen saturation was 97%. An electrocardiogram showed sinus rhythm with preexcitation. The patient's chest x-ray showed no acute pathology. His serum troponin I level was .005 nanograms/milliliter (ng/ml). He was treated with intravenous fluid and admitted to the hospital. He remained in sinus rhythm. His troponin I level was minimally elevated at .015 ng/ml. An echocardiogram showed hyperdynamic left ventricular systolic function and was otherwise unremarkable. An electrophysiologic study was performed and showed a right posteroseptal atrioventricular (AV) accessory pathway capable of bidirectional conduction. There was inducible orthodromic reciprocating tachycardia. The pathway was ablated using radiofrequency energy. The procedure was uncomplicated. An electrocardiogram showed recurrence of anterograde accessory pathway conduction. The patient was discharged with plans for outpatient follow-up. At issue is the medical necessity of an inpatient stay.

Based on the documentation provided an inpatient level of care was not medically necessary.

This patient presented after an episode of palpitations that was likely due to orthodromic reciprocating tachycardia utilizing his AV accessory pathway in the retrograde direction. By the time he was seen in the emergency department, he was hemodynamically stable and in sinus rhythm. He developed a minimal increase in his serum troponin level. However, this is common with paroxysmal supraventricular tachycardia (PSVT), even in the absence of coronary artery disease.
While there are no clear guidelines regarding disposition for patients presenting to the emergency department with paroxysmal supraventricular tachycardia (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.
This patient underwent uncomplicated electrophysiologic testing and ablation of a right posteroseptal AV accessory pathway. While it was reasonable to monitor the patient overnight post-procedure, this did not require an inpatient level of care. Same-day discharge after uncomplicated ablation of supraventricular tachyarrhythmias has been shown to be safe. Marijon et al analyzed data from 1342 patients who underwent radiofrequency catheter ablation; 94.6% of whom were discharged home the same day of the procedure. The one month readmission rate was 0.79%; there were no life threatening complications. Theodoreson et al published a retrospective review of 897 who underwent radiofrequency catheter ablation of supraventricular arrhythmias, 805 of whom were discharged home the same day. Among all patients with a same-day discharge, none had a subsequent complication that would have been detected had they remained in the hospital overnight.