Diagnosis: Cancer/Lung Cancer
Treatment: Inpatient hospital stay

This patient has a history of lymphoma and a left lung nodule status/post (s/p) video-assisted thoracoscopic surgery (VATS) wedge resection. Patient presented to the hospital for a scheduled right VATS wedge resection of a right lung nodule. The surgical procedure was uneventful, and subsequently the patient was transferred to the post-anesthesia care unit. Chest tube was discontinued on postoperative day (POD) #0. In the evening, the patient became tachycardic with a heart rate in the 140's, and soon thereafter developed chest pain/pressure and shortness of breath. An electrocardiogram was performed that demonstrated supraventricular tachycardia (SVT) with ST changes, and troponin was < 0.02. SVT did not resolve after two doses of intravenous (IV) metoprolol. Patient was given IV fentanyl and a normal saline IV bolus, but heart remained in SVT. Ultimately, the Intensive Care Unit (ICU) team was consulted and carotid massage was performed which broke the SVT, and heart converted to a normal sinus rhythm. Following these events, the patient was maintained on telemetry until discharged to home on POD #3. The health plan's determination of medical necessity is overturned in whole. This patient received appropriate attention and care, including studies to rule out myocardial infarction, pharmaceutical intervention and finally carotid massage for definitive treatment of arrhythmia after it was determined to be SVT. Following this episode, the patient experienced an uneventful recovery. However, due to the events of the first postoperative day, this patient required an inpatient level of care.
While the patient underwent an uncomplicated VATS right upper lung lobe wedge resection, postoperatively the patient developed tachycardia, chest pain and shortness of breath that required work-up and intervention at an inpatient level of care. Further, the patient required 3-midnights in the hospital, whereas a lower level, such as observation level of care, is intended for patients who are expected to stay < 2 midnights(1) and do not require the inpatient attention and care that this patient received.