Diagnosis: Cardiac/Circulatory Problems.
Treatment: Inpatient Hospital.
The insurer denied: Inpatient stay.
The denial is upheld in whole.

The patient is a male with a history of hypertension and methadone dependence, presented to the emergency department (ED) with asymptomatic bradycardia. The day prior his heart rate at his methadone clinic was 39 beats/minute. An electrocardiogram showed sinus bradycardia and he was advised to go the ED. In the ED the patient was in no distress. Upon questioning he reported several years of exertional dyspnea with walking one block. His blood pressure was 150/90 millimeters of mercury (mmHg) with a heart rate of 51 beats/minute. His physical exam was unremarkable. An electrocardiogram showed sinus rhythm at 55 beats/minute without acute changes. His brain natriuretic peptide (BNP) level was normal. Chest x-ray showed cardiomegaly and mild pulmonary vascular congestion. The patient's serum creatinine level was 1.63 milligrams per deciliter (mg/dl). He was treated with intravenous fluid and admitted to the hospital. Prior to admission he had been on carvedilol, which was stopped. His resting sinus rate ranged from the 40s-50s; with walking his heart rate increased to the 80s. The next day the patient's creatinine level was 1.18 mg/dl. Review of his prior medical records indicated that he had been evaluated in 2010 and again in 2014 for asymptomatic bradycardia. He was discharged. Medical necessity for an inpatient admission is at issue.

The health plan's determination of medical necessity is upheld in whole.

This patient was admitted to the hospital with asymptomatic sinus bradycardia. The most likely underlying etiology was intrinsic sinus node dysfunction, exacerbated by treatment with carvedilol, a beta-adrenergic blocker. He was hemodynamically stable, without signs of myocardial or cerebral ischemia. His initial serum creatinine was elevated but normalized with intravenous fluids, and then remained stable. No particular treatment for his bradycardia was provided while he was hospitalized, nor was it indicated. According to current guidelines, while it would be reasonable to assess this patient's chronotropic response to exercise at some point, no immediate intervention or inpatient hospitalization was warranted. The patient could have been managed at a lower level of care status.