Appeal type: Medical necessity
Decision: Upheld

Cardiac Inpatient hospital

Diagnosis: Atrial Fibrillation
Treatment: Inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

This man presented to the emergency department complaining of one hour of dyspnea and lightheadedness. His medical history was remarkable for type 2 diabetes, paroxysmal atrial fibrillation, hypertension and hyperlipidemia. His blood pressure was 125/96 mmHg with a heart rate of 171 beats/minute. His room air oxygen saturation was 98%. His physical exam was remarkable for a rapid irregular heart rate. An electrocardiogram showed atrial fibrillation with a rapid ventricular rate. The patient's serum troponin level was .09 ng/ml and increased to 0.21 ng/ml. His brain (or B-type) natriuretic peptide (BNP) level was normal. His blood glucose level was 471 mg/dl. Chest X-ray showed no acute pathology. The patient's rhythm spontaneously converted to sinus while he was in the emergency department. 

The inpatient hospital stay was not medically necessary.
This man presented with acute atrial fibrillation (AF). He was hemodynamically stable, he was not in decompensated heart failure, had no evidence of structural heart disease and was not at high short-term risk for thromboembolism. While his serum troponin level was elevated, this is a common finding in patients presenting with supraventricular tachyarrhythmias, including atrial fibrillation, and is not necessarily indicative of coronary artery disease or acute coronary syndrome (ACS). This patient was not thought to have, nor was he treated for, ACS. His rhythm spontaneously converted to sinus while he was still in the emergency department. For patients presenting with acute AF, the safety of observation 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."
An inpatient level of care was not medically necessary for this stable patient whose rhythm converted to sinus within hours of his presentation. While the patient's initial blood glucose level was markedly elevated, his mental status and corrected serum sodium level were normal and there was no evidence of ketoacidosis. His uncontrolled diabetes did not warrant an inpatient admission.