Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems/Arrhythmia/Irregular Heart Rhythm
Treatment: Inpatient Hospital
The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is upheld.

This man presented to an urgent care center complaining of lightheadedness. An electrocardiogram showed atrial fibrillation with a ventricular rate of 134 beats/minute. His medical history was remarkable for chronic hyponatremia. He was transported to the emergency department where he was found to be in normal sinus rhythm. He had no complaints at that time. His blood pressure was 147/81 millimeters of mercury (mmHg) with a heart rate of 87 beats/minute. He was afebrile. His serum troponin I level was .034 nanogram (ng)/milliliters (ml) and increased to .053 ng/ml when remeasured. His serum sodium level was 130 milliequivalent (mEq)/liter (L). His brain (or B-type) natriuretic peptide (BNP) and creatine kinase levels were normal. A chest X-ray showed left lower lobe atelectasis versus pneumonia. The patient was treated with aspirin and Enoxaparin and was admitted to the hospital. He remained in sinus rhythm. His troponin I level was .025 ng/ml. He was seen by a cardiologist who recommended a cardiac catheterization. This showed nonobstructive disease in the left main coronary artery and was otherwise normal. The patient had an allergic reaction to contrast dye that was treated with intravenous steroids and Benadryl. The procedure was otherwise uncomplicated. An echocardiogram showed a left ventricular ejection fraction of 50-55% (percent) with mild mitral regurgitation. The patient remained in sinus rhythm and was discharged.
At issue is the medical necessity for an inpatient admission.

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

Based on the documentation provided, an inpatient level of care was not medically necessary.
This patient had an episode of acute atrial fibrillation (AF). By the time he presented to the emergency department he was in sinus rhythm. He was hemodynamically stable, he was not in decompensated heart failure, had no evidence of significant structural heart disease and was not at high risk for thromboembolism. While his serum troponin levels were mildly 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. It is not recommended that these levels be measured based on AF alone, but only when there is reasonable suspicion of acute coronary insufficiency. For 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."