Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is overturned.

 
This is an adult with a past medical history which includes atrial fibrillation, diabetes mellitus type II after transplant, hypertension, fibroids, hyperlipidemia, renal transplant x2 with chronic rejection, and gastritis. 

She presented to the Montefiore Hospital Emergency Department (ED) with recurrent, although transient episodes of chest pain, dizziness, and shortness of breath. At the time of her presentation, she was in atrial fibrillation (AF) with rapid ventricular response (RVR) up to 140 beats per minute, but spontaneously reverted to normal sinus rhythm, at which time her symptoms improved.

In the emergency department (ED), she was evaluated by a physician who noted the transient chest pain, transient AF, and transient hypertension, as well as the fact that the patient has had three similar episodes over the course of the day. She suspected those prior episodes were also associated with AF, and recommended admission to telemetry, and was awaiting feedback from the renal transplant team. An electrocardiogram (EKG) performed while in sinus rhythm was reassuring.

A chest x-ray was normal, as was a recent echocardiogram. A stress echocardiogram was normal. Troponins were negative x2 (0.02 to 0.03). Acute Coronary Syndrome (ACS) was ruled out. An electrophysiology (EP) consult had recommended dronedarone if it was ok with the renal transplant; if not, sotalol could be considered with QT (interval on an EKG) monitoring on telemetry. Outpatient ablation could be considered.

Renal transplant saw the patient, Dronedarone was approved, although with a decrease in tacrolimus dosing and instructions to monitor tacrolimus levels before each dose. Tacrolimus is part of the patient's anti-rejection / immunosuppressant regimen.

An echocardiogram was performed, which was essentially normal, although limited.

The patient's HEART (cardiac risk score) score of 3  (2 points for cardiac risk factors, 1 for age) places her in the low risk category, and therefore suggests that hospitalization is not necessary for further assessment of chest pain. However, it is important to note that this admission was not intended to further evaluate chest pain, but rather, was intended to treat its cause. As noted by multiple providers, her pain was believed to be related to AF/RVR which correlated with spontaneous resolution of her AF. After appropriate consultation with cardiology (and, later, with the renal transplant team), antiarrhythmics were planned to help minimize recurrence of that symptomatic AF. In this case, initiation of those antiarrhythmics was complicated by her history of renal transplantation, and the need for close monitoring of her antirejection medications.

Unfortunately, dronedarone can increase tacrolimus levels which is of significant concern in this renal transplant patient, as elevated tacrolimus levels can have significant side effects, including acute renal failure. Close monitoring of tacrolimus levels in this circumstance was, therefore, appropriate, and would not have been realistic as an outpatient. 

For these reasons, inpatient hospitalization was appropriate for treating the patient's symptomatic atrial fibrillation. Specifically, her symptoms were attributed to paroxysmal atrial fibrillation, and when the decision was made to initiate anti-arrhythmic therapy to reduce these episodes, that required close monitoring of her anti-rejection medications. A brief hospital stay, longer than two midnights, was reasonably and correctly anticipated, making Inpatient status the correct medical decision for the patient.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is substantiated.