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202011-132411

2020

Fidelis Care New York

Medicaid

Cardiac/ Circulatory Problems

Inpatient Hospital

Medical necessity

Upheld

Case Summary

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

The patient is a gentleman that underwent total right hip replacement. His past medical history was significant for paroxysmal atrial fibrillation. Previous echocardiogram revealed a preserved LV (left ventricle) ejection fraction. He developed palpitations and worsening hip pain while in a rehabilitation facility. He called 911 and was taken to the hospital.

Upon arrival, the patient's physical examination was unremarkable. His pulse was 75 bpm (beats per minute). An ECG (electrocardiogram) taken prior to arrival revealed narrow complex tachycardia at a rate of 165 bpm (beats per minute). The patient was admitted to telemetry for monitoring and was subsequently discharged.

The patient's CK (creatine kinase) was elevated, but lower than previous values obtained following hip replacement surgery. CT (computerized tomography) angio of the chest demonstrated no evidence of pulmonary embolism. The patient was ultimately discharged on beta blocker and oral anticoagulant therapy.

No, the Inpatient admission was not medically necessary.

This patient presented with palpitations and had a known past history of paroxysmal atrial fibrillation. Upon arrival to the ED (emergency department), his heart rate was normal, and his arrhythmia had spontaneously terminated. He was effectively treated with AV (atrioventricular) nodal blocking agents. Pulmonary embolism was ruled out, and CPK (creatine phosphokinase) elevations were trending lower as compared to his post-operative lab tests.

Bellew et al. (et alii) studied patients presenting to the hospital with rapidly conducted atrial fibrillation and compared outcomes between those admitted to the inpatient service and those that were observed in the emergency department. In this study of almost 600 patients, there was no difference in outcome. AHA (American Heart Association) guidelines note that admission to the hospital for management of atrial fibrillation in patients that achieve rate control do not require hospital admission (Reference 2). This patient reverted to normal sinus rhythm spontaneously and was in normal rhythm upon arrival. In conclusion, this patient could have been managed at a lower level of care.

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