Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac Arrest

Treatment: Full Hospital Admission

The insurer denied coverage for Full hospital admission

The denial is overturned

This case involves a male with a prior history of sleeve gastrectomy. He presented to the emergency department complaining of a weak pulse and apnea. The patient had just undergone an abdominoplasty. The documentation does indicate Emergency Medical Services detailed the patient was in pulseless electrical activity and was given assisted ventilation. The documentation indicated the patient did undergo the procedure earlier that day at an outpatient anesthesia surgical center and after the procedure the patient was extubated and brought to recovery. He had been given propofol and Versed during the procedure. Per emergency medical services, they were called after the patient was reported to have gone into cardiac arrest. The patient become hypotensive and was noted to possibly have no pulse. Chest compressions were started. The patient did improve after a few rounds of chest compressions and was brought to the emergency department for further treatment and management. 

The physical examination revealed a heart rate of 55 beats per minute with a blood pressure of 108/54. The patient's respirations were 16 with oxygen saturation at 100 percent. The examination revealed the patient had Jackson Pratt drains in place with an abdominal pelvic binder. The physician detailed the patient was recommended to undergo laboratory studies and an electrocardiogram. It is also noted that the patient did have a witnessed seizure within the emergency department. The reevaluation revealed the patient is breathing on his own. He was able to answer questions appropriately. His blood pressure was stable. The documentation does detail the patient attempted to get out of his bed on his own. Seizure activity was noted lasting approximately 45 seconds. An electrocardiogram was ordered, and the patient was noted to be post ictal. Intravenous fluids were started for hypotension. The documentation detailed the patient was admitted for further treatment. The documentation detailed the patient's laboratory studies revealed a white blood cell count of 20.7. He continued treatment which included intravenous fluids as well as further medication. The documentation detailed the patient did undergo a transthoracic echocardiogram revealing no left atrial dilation. The left ventricular apex appeared highly trabeculated raising the possibility of non-compaction. It was recommended the patient undergo a cardiac magnetic resonance imaging.The patient did continue treatment without any further significant adverse events. The patient continued to improve and was discharged.

The submitted documentation indicated this patient was transferred from an ambulatory surgery center via emergency medical services due to cardiac arrest. The documentation indicated the patient also suffered possible seizures while in the emergency department. He was noted to be postictal and recommended for admission. The 3-day admission was appropriate given the level of care needed. This patient required continued monitoring and treatment given the prior cardiac arrest. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The insurer's denial of coverage for the full hospital admission is reversed.  Medical necessity is substantiated.