202210-154322
2022
Empire Healthchoice Assurance Inc.
Indemnity
Cardiac/ Circulatory Problems
Inpatient Hospital
Medical necessity
Upheld
Case Summary
Diagnosis: tachycardia.
Treatment: inpatient stay.
The insurer denied the inpatient stay.
The health plan's determination is upheld.
This woman was referred to the emergency department (ED) after having had an episode of wide complex tachycardia (WCT) during an outpatient cardiac stress test that was performed for atypical chest pain. She remained hemodynamically stable. It was unclear whether the WCT represented ventricular tachycardia (VT) or sinus tachycardia with left bundle branch block.
The full hospital admission was not medically necessary.
This patient was sent to the hospital for cardiac catheterization after she had a wide complex tachycardia during an outpatient stress test and there was concern that the tachycardia was ventricular in origin. She was hemodynamically stable and stress echocardiography showed no evidence of ischemia. Coronary angiography showed single vessel disease with a 60-70% right coronary artery lesion. No intervention was deemed necessary. The procedure was uncomplicated. The patient was seen by an electrophysiologist who opined that the tachycardia was sinus tachycardia with left bundle branch block (LBBB) aberrancy.
Ventricular tachycardia is a potentially lethal arrhythmia, usually associated with structural heart disease or myocardial ischemia. Given that there was concern that this patient had ventricular tachycardia, cardiac monitoring pending cardiac catheterization and cardiac electrophysiology consultation was reasonable and prudent. However, this patient was hemodynamically stable, no treatment for the tachycardia was required and echocardiography did not show evidence of ischemia or significant structural heart disease. Coronary angiography showed no evidence of an acute coronary lesion. The tachycardia was ultimately judged to be sinus tachycardia with LBBB. While exercise-induced LBBB has been associated with coronary artery disease, it does not require any treatment, and has also been shown to occur in normal hearts. Based on the documentation provided, this patient's care could have been provided at a lower level of care.