Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems
Treatment: Inpatient Hospital Stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The health plan's determination is upheld.

This man presented to his physician's office complaining of palpitations and mild chest pressure. An electrocardiogram showed atrial fibrillation (AF) with a rapid ventricular rate. His medical history was remarkable for hypertension, bicuspid aortic valve, thoracic aortic aneurysm, hyperlipidemia, and gastric sleeve surgery for morbid obesity. He was referred to the emergency department where his blood pressure was 122/89 millimeters of mercury (mmHg) with a heart rate of 162 beats/minute. His respiratory rate was 18/minute with a room air oxygen saturation of 97% (percent). An electrocardiogram showed atrial fibrillation with a rapid ventricular rate. The patient's serum troponin level was normal. A chest X-ray showed no acute pathology. He was treated with intravenous fluid and a Diltiazem bolus and continuous infusion and was admitted to the hospital. Intravenous Diltiazem was continued, and oral Metoprolol was prescribed. An echocardiogram showed normal left ventricular systolic function. There was no significant valvular disease; the report stated that the aortic valve was trileaflet. At some point during the night his rhythm converted to sinus. In the early morning of the next day he complained of dull, positional left sided chest pain. His physical exam was unremarkable. The physician's note does not mention any acute electrocardiographic changes. After sublingual Nitroglycerin the patient's blood pressure was 95/67 mmHg; it increased to 137/76 mmHg after an intravenous fluid bolus. A repeat troponin level was normal. The patient remained in sinus rhythm and was discharged.

The medical necessity for an inpatient hospital admission is at issue.

I uphold, in whole, the health plan's determination of medical necessity.

Based on the documentation provided, an inpatient level of care was not medically necessary.

This patient presented with acute AF. He was hemodynamically stable, there was no evidence of ischemia, he was not in decompensated heart failure and was not at high risk for thromboembolism. For stable 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 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."

This patient met none of these criteria.