Diagnosis: Myocardial Infarction

Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld.

This is a male patient with a medical history of paroxysmal atrial fibrillation who presented to the emergency department with complaints of fever, pain, weakness, and body aches. The patient was consulted by Cardiology. He had an electrocardiogram (EKG) the showed atrial fibrillation with rapid ventricular response. A computed tomography was done that was negative for a pulmonary embolism. He was started on Metoprolol. He was discharged home with instruction to follow up with outpatient cardiology.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. Inpatient admission was not medically necessary for this patient. In the absence of evidence of myocardial ischemia, hypoxemia, hemodynamic instability, or other end-organ dysfunction, the patient's care could have been provided in the observational setting, allowing for additional cardiac testing. Inpatient admission criteria were not met. Although the patient had new onset symptoms, medical policy criteria were not met for any other additional extenuating circumstances.

The carrier's denial of coverage for the inpatient admission from is upheld. The medical necessity is not substantiated.