Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial fibrillation with rapid ventricular response
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history significant for chronic obstructive pulmonary disease (COPD), atrial fibrillation being managed with Amiodarone, Metoprolol, and Eliquis, coronary artery disease requiring stent placement, cardiomyopathy, and hypertension who presented to the hospital with complaints of fever, chills, and palpitations in the chest. It was reported that the patient's heart rate was around 130 beats per minute (bpm). This was associated with increasing shortness of breath, sputum, and mucus production. One day before presentation, the patient noticed that their heart rate went up to 180 beats per minute (bpm). This prompted the patient to seek medical attention, and they came to the emergency department.

The patient denied chest pain, nausea, vomiting, dizziness, and syncope. Upon initial evaluation in the emergency department, the patient's temperature was 102.3 degrees Fahrenheit, heart rate 183 beats per minute (bpm), respiratory rate 18 breaths per minute, blood pressure 116/81, and oxygen saturation 97% on 2 liters of oxygen via nasal cannula. The patient was in no acute distress. The exam was notable for expiratory wheezing but no crackles. A cardiac exam revealed normal cardiac sounds with no additional heart sounds.

A laboratory evaluation revealed a white blood cell count of 9.4, hemoglobin 11.7, hematocrit 36.6, and platelets 229. Sodium was 134, potassium 4.7, chloride 96, bicarbonate 24, blood urea nitrogen (BUN) 18.3, creatinine 1.1, and glucose 110. An electrocardiogram (EKG) demonstrated supraventricular tachycardia, which was interpreted as atrial fibrillation with a rapid ventricular response. A chest x-ray revealed newly developed lingula airspace disease.
The patient was admitted to the hospital with atrial fibrillation with rapid ventricular response, chronic obstructive pulmonary disease (COPD) exacerbation, and community-acquired pneumonia. The patient received treatment with intravenous corticosteroids for chronic obstructive pulmonary disease (COPD) exacerbation, bronchodilators, and antibiotics. The patient decided to leave the hospital against medical advice. At issue is the medical necessity of the inpatient stay.

The health plan, in its determination of medical necessity, did act reasonably, with sound medical judgment and in the best interest of the patient.
 
The requested health service/treatment of inpatient hospital services was not medically necessary for this patient. According to the nationally accepted standards of care, admission at the acute inpatient level of care for patients with pneumonia is recommended in cases of hypoxemia, hemodynamic instability, severe or persistent altered mental status, dehydration, bacteremia, moderate risk or high-risk category patients based on the pneumonia severity index class four or five, or for patients who received a score of two on Confusion, urea, respiratory rate, blood pressure (CURB-65) pneumonia severity scale. Based on the Confusion, urea, respiratory rate, blood pressure (CURB-65) pneumonia severity scale, this patient received 0 points and therefore belonged to a low-risk group with 0.6% 30-day mortality.

Admission at the acute inpatient level of care is recommended for patients who failed outpatient treatment or had respiratory findings such as dyspnea that did not respond to outpatient or observation care treatment, for patients with complicated pleural effusions such as empyema, or for patients who were immunocompromised.

Furthermore, the patient had paroxysmal atrial fibrillation. The decision to admit patients with atrial fibrillation with rapid ventricular response (RVR) to the acute inpatient level of care depends on the severity of symptoms, the underlying cause, and the risk of complications. Indications for admission include patients who are hemodynamically unstable, are symptomatic despite medical therapy, have underlying medical conditions that may exacerbate symptoms or increase the risk of complications, those requiring urgent cardioversion, or are non-responsive to initial medical management. Based on the review of medical records, there was no information that would prove that the patient failed the initial treatment of atrial fibrillation with rapid ventricular response.