Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prolonged QTc
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

This is a female admitted through the emergency room (ER) with acute alcohol intoxication. The patient called Emergency Medical Services (EMS) to state she was drunk. Exam was unremarkable. Evidence of flu. Electrocardiogram (EKG) showed prolong QT and no ischemic changes. Echocardiogram showed ejection fraction (EF) of  45-50%. Magnesium was low.  The patient had multiple co-morbidities including polysubstance drug abuse, human immunodeficiency virus (HIV), gastritis, and bipolar diagnoses. The patient was admitted and she requested to see a psychiatrist. She was admitted to telemetry, received home medications, intramuscular (IM) Ativan, EKGs and lab work. She was monitored for prolonged QTc, which was corrected with magnesium supplement. A concern stated that she was unreliable for follow up as another reason for admission. The discharge summary stated that there were no signs of symptoms of angina or congestive heart failure (CHF).

No, inpatient level of care was not medically necessary.

Determination of level of care is primarily dependent on the actual care a patient receives and, whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results; and highlighted in the orders for care. 

In this case, the symptoms were atypical for coronary artery disease (CAD) and unlikely to be representative of acute coronary syndrome (ACS). Exam and cardiac findings were normal. Biomarkers and EKG showed no evidence of acute ischemia. Chest x-ray (CXR) was normal. Echocardiogram showed EF of 45-50%.  The physicians' treatment did not reflect any serious concern about patient's acute cardiac condition.  Orders did not include medical therapy for ACS such as intravenous (IV) heparin, dual antiplatelet inhibitors, high dose beta blockers or IV nitroglycerin (NTG). Prolonged QTc was corrected with supplemental magnesium. 

The letter of appeal was carefully considered but it offered no evidence to support inpatient level of care. The statement that the care "could not have been done in the outpatient setting" is not supported by the patient's care, community practice or guidelines.  The only cardiac care provided was telemetry, frequently performed in a lower level of care. The patient was admitted for monitoring and subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care. This patient had no evidence of CAD. All tests showed absence of ischemia.  While there is always a potential for an adverse event, one did not happen and no actual treatment was added.

The discharge summary specifically states no angina or CHF. Milliman criteria requirements were not fulfilled as there was never any evidence of ACS present.

All testing and therapy would be appropriate, safe and guidelines consistent to be in lower level of care. Thus, inpatient level of care was not medically necessary.

The denial explanation was consistent with guidelines and usual community care.