Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Arrhythmia/Irregular Heart Rhythm
Treatment: Inpatient hospital admission
The health plan denied the inpatient hospital admission.
The determination is upheld.

The patient is a female who presented to the emergency department (ED) complaining of palpitations, chest pain, dyspnea, and dizziness. Her medical history was remarkable for hypertension, cigarette smoking, and morbid obesity. In the ED, her blood pressure was 165/97 millimeters of mercury (mmHg) with a heart rate of 120 beats per minute (bpm). Her room air oxygen saturation was 97 percent (%). An electrocardiogram (EKG) showed atrial fibrillation (AF) with a rapid ventricular rate. Her serum troponin and brain (or B-type) natriuretic peptide (BNP) levels were normal. A chest x-ray showed no acute pathology. The patient was treated with intravenous (IV) fluid and a dose of IV metoprolol and was admitted to the hospital. Oral metoprolol was prescribed for ventricular rate control. The next day, the patient was in sinus rhythm. Myocardial perfusion imaging was performed and showed no evidence of ischemia. The patient was discharged. At issue is the medical necessity of the inpatient hospital admission.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of inpatient hospital admission was not medically necessary for this patient.

This patient presented with AF with a rapid ventricular rate. She was hemodynamically stable, there was no evidence of acute ischemia, she was not in decompensated heart failure, she had no evidence of structural heart disease, and she was not at high short-term risk for thromboembolism. Her rhythm spontaneously converted to sinus. 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." 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."

The Milliman Care Guideline (MCG) for atrial fibrillation was provided for review. This patient did not meet any of the listed criteria for inpatient hospital admission.