Appeal type: Medical necessity
Decision: Upheld

Diagnosis: /Arrhythmia/Irregular Heart Rhythm/Atrial Fibrillation
Treatment: Inpatient Hospital Admission
The health plan denied the inpatient hospital admission..
The health plan's determination is upheld.

This woman presented to the emergency department (ED) complaining of palpitations, chest tightness and diaphoresis. A previous workup for palpitations, including ambulatory electrocardiographic monitoring, was unrevealing. In the emergency department, (ED) her blood pressure was 138/83 millimeters of mercury (mmHg) with a heart rate of 130 beats/minute. Her room air oxygen saturation was 100%. An electrocardiogram showed atrial fibrillation with a rapid ventricular rate; there were no acute ischemic changes. Her serum troponin I level was .331 nanograms/milliliter (ng/ml). Her brain (or B-type) natriuretic peptide (BNP) level was normal. The patient was treated with an intravenous Diltiazem bolus and infusion and with Enoxaparin. She was admitted to the hospital. Her rhythm spontaneously converted to sinus within several hours of her presentation. She was seen by a cardiologist who opined that her serum troponin elevation did not suggest acute coronary syndrome. She was discharged.
The medical necessity for an inpatient admission is at issue.

I uphold, in whole, the health plan's determination that an inpatient level of care was not medically necessary.

Based on the documentation provided, an inpatient level of care was not medically necessary.
This patient presented with a new onset atrial fibrillation (AF). She was hemodynamically stable, there was no evidence of decompensated heart failure or structural heart disease, and she was not at high risk for thromboembolism. While her serum troponin level was mildly elevated, this is common in acute AF, even in patients without coronary artery disease. For patients presenting with acute AF, the safety of observation level care or discharge to home with close follow-up has been well demonstrated. 
As stated by Lin et al, "There is growing evidence to suggest that outpatient management is a safe and effective alternative to hospital admission for the management of many patients with acute AF or atrial flutter. Protocols for early rhythm control, clinical decision rules to guide the decision to initiate antithrombotic therapy, and low molecular weight Heparin and direct oral anticoagulants have reduced the need for acute inpatient hospitalization." Likewise, Conti et al, based on an observational study of 3475 patients concluded, "In patients with AF, beyond the standard approach, the novel organization with an additional intensive observation unit for early pharmacological interventions and an outpatient clinic for elective treatment and short-term follow-up significantly reduced admission irrespective of independent predictors of hospitalizations." Vinson et al, based on a smaller study and a review of the literature, agreed with this approach and stated, "The short-term home observation management approach for atrial fibrillation/flutter patients who present early in their symptomatic course has been mentioned in the literature (sometimes called the "wait and watch" method), but it has not been well described. In our sample, 11 of 16 patients (69%) managed with this approach spontaneously cardioverted to normal sinus rhythm within 48 h of symptom onset. Our findings are consistent with previous studies, which have reported that up to two-thirds of selected patients with presumed recent-onset atrial fibrillation spontaneously convert to normal sinus rhythm within 2-3 days."