Appeal type: Medical necessity
Decision: Upheld

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

The patient presented to the emergency department (ED) with palpitations and chest pain. The patient described his symptoms as sudden. His heart rate was 200. The patient was given Cardizem intravenous (IV) by Emergency Medical Services (EMS) and then was brought to the emergency department (ED). In the ED, the patient continued to have palpitations and chest pain. His chest pain was described as pressure-like substernal pain, and he rated it as 8/10, and it was associated with shortness of breath (SOB), diaphoresis and dizziness.
The patient has a history of eosinophilic asthma, anxiety, prostatitis and diabetes mellitus on insulin. He had an umbilical hernia without obstruction. The patient was on prednisone for his asthma and was supposed to taper it. He also was on antibiotics. In the ED, the patient's heart rate was 160 beats per minute (BPM). His blood pressure (BP) was 135/76, his oxygen (O2) saturation was 98%. His physical examination was remarkable for being mildly anxious, tachycardic. He was moderately obese and had an umbilical hernia present. Otherwise, his physical examination was unremarkable.
His chest x-ray (CXR) revealed: "mild prominence of the bronchovascular markings may be related to small airways inflammation and / or mild pulmonary vascular congestion; no frank pulmonary edema; no focal consolidation, pleural effusion or pneumothorax: no visualized acute osseous findings. The cardiac silhouette is within normal limits".
His troponin was 0.011. The patient was given Cardizem intravenous (IV), first 10 milligrams (mg), then 25 mg, then 60 mg orally. The patient also was given a fluid bolus. The patient received Aspirin 162 mg and nitroglycerin 0.4 mg sublingual (SL) with improvement of the chest pain to 2/10.
The patient was admitted to the hospital for further management. He was consulted by cardiology and it was noted that the patient presented with atrial fibrillation with rapid ventricular rate. An echocardiogram was recommended. An arterial blood gas (ABG) was recommended because of a history of severe asthma with carbon dioxide (CO2) retention. He was to avoid beta-blockers and continue Cardizem 30 mg every 8 hours. His serial troponin was 0.034. Because of the rapid ventricular rate, the Cardizem was increased to 60 mg every 8 hours. The patient converted back to sinus rhythm.
An echocardiogram was done and it revealed: no left atrial dilatation. Global left ventricular (LV) wall motion was normal. LV ejection fraction was normal (52%). The left ventricular filling pattern was normal. The right ventricle was normal size. The right ventricle had normal wall motion. The aortic valve was tri-leaflet. There was no aortic stenosis. There was no aortic regurgitation. There was trace mitral regurgitation. The right atrial pressure was normal.
The patient underwent a stress test and it revealed "small to medium size defect, of mild to moderate severity, in the basal inferior, basal infero-lateral, mid inferior and mid infero-septal walls, that it predominantly fixed, suggestive of possible infarction. The possibility of artifact cannot be excluded".
The patient was started on Xarelto instead of low molecular weight heparin. Based on this report, the cardiologist had a conversation with the patient. He was recommended to undergo coronary angiography. However, the cardiologist noted that the results could be false positive. The patient's ejection fraction was normal and the patient's exercise capacity was good. Alternatives of coronary computed tomography (CCTA) or medical management were discussed. The patient declined, and wanted to obtain a second opinion after the discharge. The patient had a close friend (or cousin), who was a nurse. The patient decided to undergo coronary computed tomography angiography (CTA) as an outpatient. The patient was discharged home.

The requested health service/treatment of inpatient stay was not medically necessary for this patient.
The patient presented with a new onset of atrial fibrillation with rapid ventricular rate and he was symptomatic with diaphoresis, chest pain and shortness of breath. He was managed appropriately for his atrial fibrillation (afib) and converted to sinus rhythm the next day. He did not have evidence of acute coronary ischemia (his troponin was low and there were no ischemic electrocardiogram (ECG) changes), there was no pulmonary edema or hypotension. The patient had changes on his CXR due to chronic severe asthma.
His ischemia work up revealed an abnormal stress test, but the cardiologist was questioning its accuracy and offered options of CCTA versus medical management along with cardiac catheterization. As a result, coronary angiography was not performed.
Based on the above information, an inpatient level of care was not medically necessary. A lower level of care would have been more appropriate.
Per the first reference: "Two recent retrospective studies evaluated the risk of thromboembolism in patients after cardioversion for AF lasting < 48 hours. In 1 study (567 cardioversions in 484 patients), the risk of thromboembolism was nearly 5 times higher in patients without therapeutic anticoagulation than in those on therapeutic anticoagulation with either warfarin or heparin, with no events in patients with a CHA2DS2-VASc [congestive heart failure (one point), high blood pressure (one point) age (two points if above 75), diabetes (one point), previous stroke or clot (two points) vascular disease (one point) age (one point if between 65 and 74), sex (one point if female)] score of < 2. In the second study, for patients with AF lasting < 48 hours and a CHA2DS2-VASc score less than or equal to (<=1), the overall event rate was low (0.4%), but this group accounted for 10 of the 38 thromboembolic events (26%) that occurred in the study. These studies agree with prior studies of cardioversion in short-term AF. In the absence of randomized trials, the risk of thromboembolic events should be weighed against the risk of anticoagulant-related bleeding for the individual patient."