Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Myocardial Ischemia

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is overturned.

This is a patient that presented to the hospital complaining of burning chest pain after eating a large meal.  Past medical history was significant for hypertension, diabetes, paroxysmal atrial fibrillation, remote deep vein thrombosis (DVT) and inferior vena cava (IVC) filter placement. Upon presentation to the emergency department (ED) the patient had a pulse of 129-134 and a blood pressure of 92/59.  Physical exam revealed an irregularly, irregular heart rhythm.  Electrocardiogram (ECG) revealed atrial fibrillation at a rate of 129 beats per minute (bpm) a prolonged QTc (intervals on ECG) interval (509) and T (intervals on ECG) wave inversions in the inferior leads. Repeat ECG revealed atrial flutter with ventricular rates up to 134 bpm. Serum blood testing revealed an escalating serum troponin level (0.012 to 0.073ng/ml [nanogram per milliliter]).  Home medications included Xarelto and Sotalol.  The patient was admitted for observation and treatment of non ST (interval on ECG) elevation myocardial infarction (NSTEMI) and atrial fibrillation (AF) with rapid ventricular response (RVR) as well as hypotension.  Echocardiogram revealed a preserved left ventricular ejection fraction (LVEF) with normal valvular function.  Cardiac catheterization revealed non obstructive coronary disease. The patient was discharged on medical therapy.

The health plan did not act reasonably with sound medical judgement and in the best interest of the patient.  This patient presented with chest burning, AF with rapid ventricular rates and hypotension with a systolic BP (blood pressure) of 92mmHg (millimeter of mercury).  ECG and troponin levels were consistent with a diagnosis of NSTEMI. In addition, the patient had a prolonged QT (intervals on ECG) interval on ECG and was treated with sotalol.  Acute inpatient admission was necessary to treat this patient and ensure that she was on appropriate medical therapy for cardiac ischemia, atrial fibrillation, hypotension and QT prolongation on ECG.

Patients presenting with atrial arrhythmia and ventricular rates up to 130 require acute therapy and further monitoring to ensure that medications control heart rate and rhythm without producing significant bradycardia. An analysis of 68 million Medicare patients admitted to the hospital for atrial fibrillation over a fifteen-year period demonstrated an average length of stay of 3 days. (Reference 1) This analysis also demonstrated decreased mortality and readmission rates following admission to the hospital.  The current standard of care is consistent with hospital admission when patients present with symptomatic rapidly conducted atrial fibrillation. In addition to AF, this patient had a prolonged QT interval on ECG and was treated with sotalol.  American Heart Association/American College of Cardiology (AHA/ACC) Guidelines for the management of atrial fibrillation recommend careful telemetry monitoring for patients treated with class III (3) antiarrhythmic agents as QT prolongation can lead to ventricular arrhythmia and even sudden cardiac death. Finally, in addition to the aforementioned, this patient had evidence of myocardial ischemia on ECG and serum blood testing and appropriately underwent cardiac catheterization prior to discharge. (3)  In conclusion, acute inpatient admission was medically necessary in this case. 

The insurer's denial of coverage for the inpatient hospital admission is overturned. Medical Necessity is substantiated.