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202105-137613

2021

Empire Healthchoice Assurance Inc.

Indemnity

Cardiac/ Circulatory Problems

Inpatient Hospital

Medical necessity

Upheld

Case Summary

Diagnosis: Chest Pain and Palpitations.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.

The denial is upheld.

The patient, a male, has a past medical history significant for stress induced tachycardia, psoriasis, obesity and tobacco abuse. The patient presented for evaluation of tachycardia after shoveling snow.

The patient was found to have sinus tachycardia. Electrocardiogram (ECG) revealed no ischemic changes. Initial troponin was 0.087, repeat troponins were normal. Chest x-ray (CXR) was unremarkable. The patient was treated with Verapamil for sinus tachycardia. No inpatient ischemic work-up was planned and the patient was planned for outpatient cardiology follow-up.

No, the proposed inpatient admission was not medically necessary.

The patient presented with sinus tachycardia. The blood pressure was stable. There was no evidence of acute myocardial infarction, acute coronary syndrome (ACS), decompensated congestive heart failure (CHF), malignant arrhythmia or hemodynamic instability. Although the initial Troponin level was mildly elevated, the repeat levels were normal. The patient improved clinically with intravenous (IV) fluids and verapamil and was discharged home with a plan for outpatient follow-up. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission and the care required could have been provided at a lower level of care.

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