CLINICAL SUMMARY:
A previously healthy six-year-old boy arrived in the emergency department with chest pains and a high heart rate of 240 bpm. Upon arrival, he was hemodynamically stable and had no mental status changes. The symptoms began during an evening soccer practice and continued once he was at home. His mother, who has a history of supraventricular tachycardia (SVT) and two ablations in adolescence, noticed a rapid heartbeat and took the child to the hospital. Doctors diagnosed the child with SVT supported by an electrocardiogram (EKG). Upon admission, the patient’s labs showed chloride high at 109mmol/L and glucose high at 122 mg/dL; the remaining labs were within normal range. He did not respond to vagal maneuvers; therefore, doctors administered 3 mg of adenosine via peripheral IV. He returned to normal sinus rhythm following adenosine administration. Emergency room treating physicians consulted pediatric cardiology and expressed concern for possible atrial flutter and premature atrial contractions on EKG following conversion. Therefore, doctors admitted the patient to the pediatric intensive care unit (ICU) for continuous cardiac monitoring.
The next morning, a repeat EKG showed sinus rhythm with no ventricular preexcitation. Staff performed a transthoracic echocardiogram with pediatric cardiology at bedside, in addition to a thyroid study. They were within normal limits. The pediatric cardiologist recommended starting atenolol and following up with them in one month with a tentative plan to ultimately do an ablation given family history. The child tolerated the first dose of atenolol, and return precautions were reviewed with family prior to discharge. Upon discharge, the patient was medically stable with no further episodes of SVT. Vitals remained stable and within normal limits, and the pediatric cardiology clinic scheduled a follow-up appointment.
INPATIENT STAY DENIAL
INPATIENT STAY DENIALThe commercial insurance organization denied the inpatient level of care for the overnight stay in the pediatric intensive care unit (ICU) even though doctors felt the patient was at high risk of cardiorespiratory decompensation. Doctors also felt the patient required continuous cardiac monitoring. The denial offered the hospital a peer-to-peer discussion regarding the denial.
THE APPRISEMD METHOD
THE APPRISEMD METHODAn AppriseMD physician advisor conducted the peer-to-peer discussion with the insurance company’s medical director regarding the inpatient stay of less than 14 hours. The physicians discussed the patient’s young age, 6 years old, and the evaluation of chest pain and a rapid ventricular rate of 240. AppriseMD’s physician advisor reiterated the fact that the patient was diagnosed with SVT, seen by cardiology and treated with adenosine. The patient had clinical improvement but still required continuous monitoring during the stay. Also discussed was the patient’s family history of SVT requiring ablation that put the child at high risk for developing cardiac arrhythmias, a potentially life-threatening condition. Ultimately, the insurance company overturned the denial based on this, combined with the patient’s young age and the need for pediatric cardiology consultation and evaluation. The inpatient level of care was approved despite a short, one-night length of stay, and the hospital was reimbursed for the services they provided.