Diagnosis: Chest Pain, Dyspnea
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a female patient who presented to the emergency department (ED) via Emergency Medical Services (EMS) for a 40 minute episode of chest pain and dyspnea. EMS found the patient to be in atrial fibrillation (AF) with a rapid ventricular rate. Her medical history was remarkable for hypertension. She admitted to noncompliance with her prescribed antihypertensive regimen. An electrocardiogram showed atrial fibrillation with a rapid ventricular rate. Her initial high sensitivity troponin and brain (or B-type) natriuretic peptide (BNP) levels were normal. The patient was sedated and electrically cardioverted to sinus rhythm. Her chest pain resolved. Her post-cardioversion electrocardiogram showed no acute ischemic changes. Her serum troponin level rose from 5 nanograms per liter (ng/L) pre-cardioversion to 2840 ng/L post-cardioversion. The patient was admitted to the hospital. She remained asymptomatic and in sinus rhythm. Computed tomography (CT) angiography showed no obstructive coronary artery disease. There was a left subsegmental pulmonary embolism. An echocardiogram was unremarkable. The patient was anticoagulated. She remained stable and was discharged. The medical necessity of an inpatient admission is at issue.
Based on the documentation provided, an inpatient level of care was medically necessary.
This patient presented with chest pain and acute atrial fibrillation with a rapid ventricular rate. She was successfully cardioverted to sinus rhythm in the emergency department. Her chest pain resolved with restoration of sinus rhythm. However, chest imaging revealed a subsegmental pulmonary embolism. Her serum troponin level increased more than 500-fold to 2840 ng/L. While minor elevations are common with atrial fibrillation and, to some extent, after electrical cardioversion, elevations to this degree are very unusual with AF and with cardioversion. Patients with pulmonary embolism levels greater than 16 ng/L are associated with an increased risk of in-hospital adverse outcomes (odds ratio 6.5) and all cause mortality (odds ratio 3.7). Given this patient's risk for major adverse events, she required careful and continuous monitoring with the ability to intervene emergently, if needed. This warranted an inpatient admission.