Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atrial Fibrillation with Rapid Ventricular Response
Treatment: Inpatient Admission

The insurer denied coverage for inpatient admission. The denial is overturned.

This is the case of a patient who presented to the hospital complaining of several days of palpitations and lightheadedness. Past medical history was significant for Marfan's syndrome status post aortic valve repair one year before presentation, hypertension, stroke, and postoperative atrial fibrillation. Upon presentation to the emergency department (ED), the patient had a pulse of 110 and a blood pressure of 109/68. A physical exam revealed an irregularly, irregular heart rhythm and no other significant abnormality. An electrocardiogram (ECG) revealed atrial fibrillation at a rate of 140 and non-specific T-wave abnormalities. Serum blood testing revealed an escalating serum troponin level peaking at 104. The patient was admitted for observation and treatment of non-ST elevation myocardial infarction (NSTEMI) and atrial fibrillation (AF) with rapid ventricular response (RVR) as well. An echocardiogram revealed a preserved left ventricular ejection fraction (LVEF) (58% [percent]) with 2+ mitral regurgitation and 2+ aortic regurgitation. Telemetry revealed periods of atrial flutter with ventricular rates up to 140. The patient reverted to sinus rhythm following treatment with beta blocker and oral anticoagulant therapy and was ultimately discharged with cardiology follow-up.

The health plan did not act reasonably with sound medical judgment and in the patient's best interest. This patient presented with lightheadedness, AF, and atrial flutter with rapid ventricular rates. Troponin levels were consistent with a diagnosis of type II myocardial infarction. Acute inpatient admission was necessary to treat this patient and ensure that he was on appropriate medical therapy for cardiac ischemia and atrial fibrillation.

Patients presenting with atrial arrhythmia and ventricular rates up to 130 require acute therapy and further monitoring to ensure that medications control heart rate and rhythm without producing significant bradycardia. An analysis of 68 million Medicare patients admitted to the hospital for atrial fibrillation over a fifteen-year period demonstrated an average length of stay of 3 days (1). This analysis also revealed decreased mortality and readmission rates following admission to the hospital. The current standard of care is consistent with hospital admission when patients present with symptomatic rapidly conducted atrial fibrillation. American Heart Association (AHA)/American College of Cardiology (ACC) Guidelines for managing atrial fibrillation recommend careful telemetry monitoring for patients with rate and rhythm control. In addition to those mentioned above, this patient had evidence of myocardial ischemia based on serum blood testing and was appropriately monitored and treated before discharge (3,4). In conclusion, acute inpatient admission was medically necessary in this case.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably, with sound medical judgment, and in the patient's best interest. 

The medical necessity for inpatient hospital services is substantiated.