This patient was sent to the emergency department by his cardiologist because of an abnormal electrocardiogram (EKG) with a plan for a left heart catheterization. The patient has a history of hypertension, end-stage renal disease (on hemodialysis), anemia secondary to end-stage renal disease, chronic gastrointestinal bleed, recent methicillin-susceptible Staphylococcus aureus bacteremia with infectious endocarditis and severe aortic regurgitation. He was recently hospitalized and a transesophageal echocardiogram at that time showed no vegetation but the patient was discharged on intravenous antibiotics to complete a six-week course for presumed infectious endocarditis. The long-range plan included left heart catheterization and cardiothoracic surgery for possible aortic valve replacement. The patient was found to have an upper lung cavity lesion, which was negative for tuberculosis and thought to be possibly due to septic emboli. A left heart catheterization was performed and showed no evidence of coronary artery obstructive disease.

The insurer denied coverage for the inpatient hospital services as not medically necessary. The denial was reversed.

This patient had bacterial endocarditis and was receiving antibiotic therapy prior to aortic valve replacement for severe aortic regurgitation. The issue being discussed is whether or not he needed hospital admission and EKG monitoring because of concern of a cardiac abscess. His cardiologist was concerned about this complication because of a prolonged PR interval and at least one reported episode of Mobitz type I second-degree atrioventricular block. The literature that has been cited indicates that myocardial abscess is not a common complication for patients with endocarditis, but it is a complication that carries a very high mortality. The literature cited shows that it is not always easy to diagnose and if the diagnosis is made too late the patient may have already developed severe consequences or have died. Because this complication is rare and extremely serious, this reviewer agrees that it is reasonable to act in the best interests of the patient by monitoring him as closely and carefully as possible. Because of these factors inpatient admission was medically necessary. It should be noted that his needed aortic valve replacement took place during this period of time.