Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Myocarditis 
Treatment: Inpatient Hospital Admission 
The insurer denied the inpatient hospital admission. 
The denial is overturned. 

This patient is a male with a prior history of myocarditis who was transferred to an emergency department for evaluation of chest pain and throat pain. Records provided for review indicate that the patient presented with chest pain and throat pain that started 2 days after receiving Pfizer coronavirus (COVID) booster. Notable labs showed creatine phosphokinase (CPK) at 245, elevated creatine kinase-blood (CK-MB) at 7.9, elevated cardiac troponin at 2.8 that down trended.

The patient was admitted to the telemetry service under an inpatient level of care for evaluation and treatment of chest pain concerning for acute myocarditis. Echocardiogram was obtained demonstrating normal cardiac function, normal wall motion, and no pericardial effusion. Blood cultures, erythrocyte sedimentation rate (ESR), and throat culture were obtained. An electrocardiogram (ECG) was normal. Cardiology service was consulted, and the patient was diagnosed with myopericarditis. The patient was treated with nonsteroidal anti-inflammatory drug (NSAID) and colchicine for a planned course of 3 months. The patient was discharged home the following day in stable condition.

At issue is the medical necessity of the inpatient hospital admission.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of inpatient hospital admission is medically necessary for this patient.

The inpatient level of care for evaluation, monitoring, and management of acute myopericarditis is medically necessary and appropriate. Myocarditis or myopericarditis is an inflammatory disease of the heart that occurs as a consequence of infections, toxin exposure, and after COVID-19 vaccination. (1) According to published medical literature on acute myocarditis, the majority of patients usually recover without long lasting adverse cardiac effects. However, the clinical course of patients diagnosed with acute myocarditis is unpredictable and myocarditis associated complications can occur including left ventricular dysfunction, heart failure and cardiogenic shock, ventricular arrhythmias, and sudden death. (2,3) Along these lines, patients with acute myocarditis can rapidly deteriorate resulting in progressive heart failure, shock, and death. Because of this, hospitalization under the inpatient level of care is recommended for patients presenting with acute myocarditis accompanied by elevated cardiac troponin for close telemetry monitoring, serial lab testing (cardiac troponin, blood counts, and end-organ function), comprehensive diagnostic testing, and for determination of cause specific treatment. (4) Because the patient's diagnosis of acute myopericarditis is associated with risk of progression to symptomatic heart failure with left ventricular (LV) dysfunction, ventricular arrhythmias, shock, and sudden death that is most appropriately evaluated and treated under an inpatient level of care.

Therefore, the requested health service/treatment of inpatient hospital admission is medically necessary.