Appeal type: Medical necessity
Decision: Upheld

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

This is a female patient with a past medical history of asthma who presented to the emergency room due to intermittent palpitations. The palpitations lasted for a few minutes and occurred every other day. The patient denied chest pain and shortness of breath but endorsed anxiety. There were no suicidal or homicidal ideations. She denied a fever, chills, cough, syncope, headache, and dizziness. The patient denied any thyroid issues but reported alcohol consumption over the weekend, with an estimated intake of less than 5 drinks per week. She also reported daily tobacco and marijuana use. The initial electrocardiogram (EKG) showed sinus tachycardia with ST depression in multiple leads.

On physical examination, the patient appeared to be a young female in a normal state, and auscultation of the chest revealed normal heart sounds (S1 and S2). The lungs were clear, the abdomen was soft, and there was no edema in the extremities. Neurologically, no focal deficits were noted.

During the hospital course, the patient's sinus tachycardia and uncontrolled blood pressure were addressed. The patient was started on metoprolol and later amlodipine was added. Hydralazine was also initiated due to a persistently high blood pressure. Acute coronary syndrome (ACS) was ruled out, and an echocardiogram showed no significant abnormalities.
As the patient did not have a primary care provider, a referral was made for a primary care physician (or provider) (PCP). A cardiology follow-up appointment was scheduled for a Zio patch, which is a wearable device for cardiac monitoring.
The patient underwent a computed tomography (CT) angiogram of the chest that was negative for a pulmonary embolism (PE) but revealed pre-existing emphysema and pulmonary nodules. The patient was informed about involving a pulmonologist for further evaluation, but she opted to defer this and requested a referral for an outpatient pulmonology appointment. Upon discharge, the patient was prescribed Amlodipine, Hydralazine, and Toprol.
Education was provided regarding tobacco cessation. The patient was deemed medically stable for discharge and was transitioned to outpatient care. 
The patient did not have clinical signs of hypertensive emergency. The patient's blood pressure measurements were elevated (150/109 millimeters of mercury (mmHg)), but they did not meet the threshold of a systolic blood pressure (SBP) greater than 180 mmHg or diastolic blood pressure (DBP) greater than 120 mmHg with evidence of acute or worsening target organ damage.
The patient's clinical presentation did not indicate acute or worsening target organ damage such as hypertensive encephalopathy, cerebral infarction, intracranial hemorrhage, myocardial ischemia or infarction, heart failure, aortic dissection, increased creatinine, papilledema, retinal hemorrhage, microangiopathic hemolytic anemia, or seizure. The patient's palpitations were not associated with cardiac arrhythmias of immediate concern. Therefore, admission at the acute level of care was not indicated in this case. This with coincided with the Milliman Care Guidelines (MCG) Health Inpatient & Surgical Care 26th Edition criteria for Hypertension, which were provided. There was no evidence that those criteria were met in this clinical case to justify admission at the acute inpatient level of care. There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at the observation level of care with subsequent transition to outpatient care, rather than admission to an inpatient level of care.
Overall, this patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.