Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Palpitations. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for the inpatient hospital admission.  The denial is upheld. 

This is a female patient who presented to the emergency department (ED) complaining of palpitations and shortness of breath. Her past medical history includes hypothyroidism and premature supra ventricular tachycardia (PSVT). She also has a history of cardiac ablation. She had two ablations performed in the past for ectopic atrial tachycardia. In spite of this she had recurrent episodes, although infrequent. The assessment and plan stated that this is a female patient with palpitations, history of ablation, now with palpitations and very frequent atrial premature complexes. 

Observation medicine research over the ensuing decades evolved along with innovations in health care. In the 1970s, studies focused broadly on the use of short-stay units in emergency departments. This focus continued in the 1980s with an increasing focus on specific conditions, in particular chest pain. Studies explored other clinical areas, such as pediatrics, geriatrics, trauma, asthma, and abdominal pain. The prevalence and scope of ED observation units (EDOUs) were described. The 1990s saw high quality observation medicine research flourish with federally funded prospective randomized clinical trials. Chest pain research refined patient selection and diagnostic testing using the term, accelerated diagnostic protocols (ADPs). Chest pain protocols in dedicated units were reported to have better outcomes than inpatient admission in terms of shorter length of stays, lower costs, less diagnostic uncertainty, and improved patient satisfaction. Similar findings were reported in accelerated treatment protocols for asthma with shorter stays. In the new millennium, ED observation unit (EDOU) research addressed new conditions, including syncope, transient ischemic attack, and atrial fibrillation. Studies described the role of observation for pediatric conditions, the elderly, and hospital operations. In the second decade of the millennium, clinical research continued as health services research focused on the impact of observation medicine on hospitals, health systems, and health policy (Ross & Granovsky). 

There are 4 main types of observation care, depending on the use of a dedicated space for observation and protocols to guide clinical care. The primary focus of this article is on type 1 observation units (OUs). Type 1 settings are dedicated OUs that are managed through protocol-driven care. Research has demonstrated this structure as superior to other types of OUs. Prospective randomized studies of patients with chest pain, asthma, transient ischemic attack, syncope, and atrial fibrillation managed in an EDOU have shown improved patient satisfaction, shorter lengths of stay, lower costs, and comparable or improved clinical outcomes relative to similar patients admitted to an inpatient floor (Conley et al.). 

This patient presented to the hospital complaining of palpitations and anxiety. Her electrocardiogram (EKG) showed normal sinus rhythm (NSR) with multiple apical premature beats (APB) and did not show supra ventricular tachycardia (SVT). Computed tomography (CT) pulmonary angiogram, chest X-ray, lab tests and physical exam were all normal. The literature cited shows that the concept of an observation unit has evolved over the last decade to include care of patients, with many different types of problems, but do not need acute hospital care. This patient did not require acute level of hospital care. 

The health plan acted reasonably with sound medical judgment.

The medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial is upheld.