Diagnosis: Symptomatic Bradycardia.

Treatment: Inpatient stay.

The insurer denied coverage for inpatient stay.

The denial is upheld.

This patient presented to the hospital complaining of chest pain and palpitations over a four-month period. Past medical history was significant for hypothyroidism. Vital signs were stable on presentation (blood pressure (BP) 149/78, Pulse 50). Physical examination was significant for left lower extremity tenderness in the popliteal area and a goiter. Serum blood testing revealed normal thyroid function studies, mild anemia with a hemoglobin of 10.7g/dl (grams per deciliter), and no elevation in troponin (<0.01). A 12- lead electrocardiogram revealed sinus bradycardia at a rate of 45bpm (beats per minute) and prolongation of the PR (interval EKG [electrocardiogram]) (233 Millisecond). Venous duplex study of the lower extremities revealed no evidence of deep vein thrombosis (DVT). The patient was admitted to the hospital for evaluation and treatment of symptomatic bradycardia. Telemetry monitoring demonstrated heart rates in the 40 range with an increase to 90bpm with ambulation. The patient was found to have no evidence of chronotropic incompetence and was discharged home.

The health care plan acted reasonably, with sound medical judgment and in the best interest of the patient. There were no significant abnormal findings on physical examination to warrant acute inpatient hospital admission. Most patients with palpitations can be evaluated in the outpatient setting (Reference 1-2). Electrocardiogram demonstrated sinus bradycardia and there was no evidence of chronotropic incompetence, the patient's heart rate increased to 90 bpm on ambulation. In one study, over 300 patients presenting with heart rates less than 50bpm had no increase in cardiovascular morbidity or mortality over a ten-year period. In conclusion, acute inpatient hospital admission was not medically necessary in this case.

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

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