Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial Fibrillation 
Treatment: Inpatient Hospital Stay 

The insurer denied the inpatient hospital stay. The determination is upheld. 

The patient has a history of paroxysmal atrial fibrillation, nonobstructive coronary artery disease, diabetes, hypertension and hyperlipidemia. He was sent to the emergency department (ED) from an internal medicine clinic. He had presented to the clinic for routine follow-up and was found to be in atrial fibrillation with a rapid ventricular rate. In the ED his blood pressure was 136/98 millimeters of mercury (mmHg) with a heart rate of 156 beats/minute. His room air oxygen saturation was 97%. On physical exam he had a rapid, irregular heart rate. The exam was otherwise unremarkable. The patient's serum troponin level was normal. A chest x-ray showed no acute pathology. He was treated with a dose of intravenous diltiazem and was admitted to the hospital for management of atrial fibrillation. He was started on oral metoprolol. An echocardiogram showed a normal left ventricular ejection fraction. Apixaban was prescribed for thromboprophylaxis. His rhythm converted to sinus. He was discharged. At issue is the medical necessity of an inpatient admission. 

An inpatient stay was not medically necessary. This patient presented with atrial fibrillation with a rapid ventricular rate. He was asymptomatic and hemodynamically stable. There was no evidence of ischemia, he was not in heart failure, and was not at high risk for thromboembolism. For stable patients presenting to the emergency department with atrial fibrillation, 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 atrial fibrillation (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 3,475 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 hours 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."