Diagnosis: Palpitations
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

The Inpatient admission was medically necessary.

The patient is a male with a past medical history significant for HTN (hypertension), dyslipidemia, aortic stenosis, and coronary artery disease (CAD). He was status post recent open heart surgery with bioprosthetic aortic valve replacement and coronary artery bypass surgery with two arterial grafts placement (less than a month prior to the admission).

The patient presented to the ER with palpitations and was found to be in atrial flutter with rapid ventricular rate. His pulse was elevated at 146/minute, and he had tachypnea. Initially, the patient was treated with IV (intravenous) Diltiazem and started on a drip, which failed to control the rate. The patient was then treated with IV Amiodarone and started on oral load, however his arrhythmia persisted.

The patient was admitted to ICU, and cardiology consultation was obtained. His arrhythmia continued despite medical therapy. He was started on Heparin drip and TEE (transesophageal echocardiogram)-guided electrical cardioversion was performed the day after admission with conversion to normal sinus rhythm. Echocardiogram revealed a moderate size pericardial effusion, and he was started on steroid therapy for suspected Dressler's syndrome. The patient was discharged home the day after admission with a plan for outpatient follow-up with cardiology and CT surgery.

The patient presented with new onset atrial arrhythmia, uncontrolled heart rate, despite treatment with two intravenous antiarrhythmic agents in the ER. In addition, the patient has increased risk of complications due to his co-morbidities and recent open-heart surgery. There was increased risk of bleeding with the use of anticoagulation, due to his recent surgery, and the newly diagnosed pericardial effusion. He eventually required TEE-guided cardioversion, as he failed medical therapy with antiarrhythmics. Given this presentation, acute uncontrolled atrial arrhythmia, as well as multiple risk factors, co-morbid conditions and known CAD, s/p (status post) recent open-heart surgery, it would be consistent with the current standard of care that this patient be managed in an inpatient setting. Therefore, the requested inpatient admission was medically necessary in this clinical setting.