Diagnosis: Tricuspid valve vegetation.

Treatment: Inpatient Hospital Admission.

The insurer denied coverage for the Inpatient Hospital Admission.

The denial is overturned.

This is a male patient with a past medical history significant for endocarditis, substance abuse, bacterial meningitis, deep venous thrombosis (DVT), and schizoaffective disorder who presented to the hospital for evaluation of inpatient rehabilitation after recent methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia, endocarditis, and septic emboli. The patient was initially transferred for acute rehabilitation, but desaturated to 70s, and became tachycardic with complaints of rigors and chest pain. While he was admitted for acute rehabilitation the patient clearly needed medical/surgical acute inpatient care and was thus transferred to inpatient care. The patient's repeat transthoracic echocardiogram (TTE) showed right ventricular failure due to persistent endocarditis. The patient's computed tomography (CT) scan of the chest showed bilateral multifocal opacities. Cardiovascular Surgery and Infectious Disease services were consulted. The patient was admitted to the cardiac care unit (CCU) for catheter directed extraction of tricuspid vegetation. The patient's magnetic resonance imaging (MRI) of the lumbar spine was done to evaluate other source of metastatic infection. Post-operative course was uneventful and the patient was ultimately discharged to continue outpatient management.

According to documentation, although the patient was initially admitted for rehabilitation, the patient was hemodynamically unstable with tachycardia (heart rate ranging from 130 to 150), and low oxygen saturation (~77% on room air), and complaints of shaking chills. The patient's echocardiogram revealed mobile tricuspid valve vegetation, right-sided heart failure, pulmonary hypertension, as well as other cardiac abnormalities requiring consultations from Infectious Disease, Cardiology, and Cardiovascular services. The patient required surgical intervention for tricuspid valve vegetation removal. Based on above findings, inpatient hospital admission was medically warranted for surgical management of progressive worsening tricuspid valve (TV) endocarditis, with previous failure of intravenous (IV) antibiotics, in a high-risk patient with numerous co-morbid conditions.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The medical necessity for the Inpatient Hospital Admission is substantiated. The insurer's denial should be overturned.