Diagnosis: Palpitations
Treatment is an inpatient admission
The insurer denied coverage for an inpatient admission
The denial is upheld

This is the case of an adult female that presented to the hospital complaining of sudden onset palpitations. Her medical history was significant for being pregnant. Upon arrival to the hospital vital signs were stable with blood pressure (BP) 120/81 and heart rate 94. No abnormal findings were noted on physical examination. A 12-lead electrocardiogram (EKG) revealed sinus rhythm with no ST (interval on an EKG) or T (interval on a EKG) wave abnormalities. Serum blood testing revealed an elevated troponin 0.069 and .038 nanogram/ milliliter (ng/ml) and an elevated D-dimer of 2.66. A computed tomography (CT) angiogram was negative for a pulmonary embolism. She was admitted to the hospital for monitoring and treatment. Evaluation by obstetrics/maternal/fetal medicine revealed no fetal abnormalities. An echocardiogram revealed normal right ventricular and left ventricular function. The patient was ultimately discharged home the day after presentation.

This patient presented with palpitations and a mildly elevated troponin level. Her pretest probability of coronary artery disease was low. Utilizing the HEART (History, EKG, Age, Risk factors, and troponin) score she was considered low risk. Utilizing the TIMI (Thrombolysis in Myocardial Infarction) risk score she also had a low risk of developing major adverse cardiac events in the subsequent 30 days. Risk assessment of patients presenting with chest pain and no significant ST changes on the EKG was reviewed by Hedayati et al. Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events [defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death] in the six weeks following presentation. Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation. In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary. This patient could have been treated at a lower level of care.

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

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