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202208-152923

2022

Empire Healthchoice Assurance Inc.

Indemnity

Cardiac/ Circulatory Problems

Inpatient Hospital

Medical necessity

Upheld

Case Summary

Diagnosis: Coronary Artery Disease
Treatment: Full Hospital Admission
The insurer denied coverage for full hospital admission.
The denial is upheld.

This is an adult that presented to the hospital for elective cardiac resynchronization implantable cardiac defibrillator insertion. Past medical history was significant for non-ischemic systolic congestive heart failure, diabetes mellitus, and prostate cancer. Electrocardiogram revealed PR (interval on EKG [electrocardiogram]) interval prolongation and left bundle branch block. Prophylactic Implantable Cardioverter Defibrillator (ICD) was recommended. The patient underwent uncomplicated cardiac resynchronization therapy (CRT) ICD implantation and was discharged the following day.

Several studies referenced have demonstrated that following uncomplicated ICD implantation same day discharge is safe and feasible (Reference 1-3).

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the full hospital admission is upheld. Medical Necessity is not substantiated.

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