Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial fibrillation with rapid ventricular response
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

This is a patient with a past medical history which includes cerebrovascular accident, gout, hypertension, atrial fibrillation, and an automatic implantable cardioverter-defibrillator (ICD) initially implanted for heart failure with reduced ejection fraction (HFrEF) of 40% (although ejection fraction had subsequently normalized to 60%), unspecified heart failure, and morbid obesity with body mass index (BMI) of 45.

The patient presented to the Emergency Department (ED) with pain and swelling in his ankles and legs which had limited his mobility for two days, as well as with right shoulder pain. 

His initial ED evaluation showed a heart rate of 107 beats per minute, his temperature was 100.5 Fahrenheit, and his vital signs were otherwise unremarkable. Electrocardiogram (EKG) and exam were consistent with atrial fibrillation with rapid ventricular response. There was concern for congestive heart failure (CHF) exacerbation. A chest Xray, intravenous (IV) Toradol, and an orthopedics consult, with admission, were planned.

He was started on low-dose metoprolol for rate control. Colchicine and prednisone were started for his gout flare. 

Orthopedics consulted. Septic joint was not felt to be present. The presentation was consistent with gout, and it was noted that he had not been taking his gout medication. Rheumatology evaluation was recommended.

Rheumatology consulted. Steroid taper and ice were recommended, with consideration of outpatient febuxostat to lower urate, as well as possible articular steroid injection. It was noted that he had been seen in the rheumatology clinic one month earlier, where he was started on colchicine, but that he had subsequently stopped the colchicine after another physician suspected it was causing side effects.

Electrophysiology consulted and noted that the patient had missed a number of device clinic appointments. He had been taking amiodarone for 6 years due to a prior shock from his ICD. His ICD was found to be in EOS (end of service) status for two years. ICD generator change was planned for the next day. This procedure was ultimately performed. 

Prednisone was changed to IV solumedrol, with a taper planned over the next few days. Pain was improved, heart rate was in the 70s. Colchicine was stopped due to possible interactions with amiodarone. Generator change was re-scheduled, although no reason for the rescheduling was mentioned in the submitted documentation.

Over the following days, progress notes remained consistent with a largely unremarkable hospital course. 
There were no clear indications given regarding the need for inpatient treatment. The issues of concern at the time of admission included gout and atrial fibrillation. Soon thereafter, it was noted that his ICD had reached EOS two years earlier. None of these three issues warranted admission. It appears likely that of the six days he spent in the hospital, five were essentially waiting for the ICD generator change to take place.

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

The insurer's denial of coverage for inpatient admission is upheld. Medical Necessity is not substantiated.