Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrioventricular Re-entry tachycardia

Treatment: Inpatient Admission

The insurer denied the inpatient admission. The denial was upheld.   

This is a female patient with a history of anxiety, hyperthyroidism and Wolf Parkinson White syndrome. She was admitted to the hospital for a planned atrioventricular re-entry tachycardia (AVRT) ablation. It was reported that the patient had a history of supraventricular tachycardia. The patient underwent a cardiac ablation with no complications. The patient was admitted to the hospital for further monitoring on telemetry. A post procedure electrocardiogram was performed that revealed EKG normal sinus rhythm and some beats with pre-excitation. The patient's groin catheterization site had a dressing in place, positive pedal pulses were noted. The patient remained medically stable and was discharged home with follow up instructions for the electrophysiologist.   

A 2009 study(1) looked at the safety and feasibility of same day discharge after Radiofrequency Catheter Ablation (RCA).  The aim of this prospective, multicenter cohort study was to evaluate the feasibility and safety of RCA in 1,342 patients considered eligible for ambulatory RCA, according to specific set of criteria.  Patients suitable for early discharge (4 to 6 hours after uncomplicated RCA) were scheduled for 1-month follow-up.  Predictive factors for delayed complications were studied by multivariate analysis.  Of the 1,342 enrolled patients, 1,270 (94.6%) were discharged the same day and followed for 1 month; no deaths occurred, and the readmission rate was 0.79% (95% confidence interval 0.30% to 1.27%).  Six patients had significant puncture complications, 2 presented with symptomatic delayed pulmonary embolism, and 2 had new onset of poorly tolerated atrial flutter.  None of these complications was life threatening.  The study concluded that these data suggest that same-day discharge after uncomplicated RCA for routine supraventricular arrhythmias is safe and may be applicable in clinical practice.  This approach was known to be associated with significant patient satisfaction and cost savings and can be considered a first-line option in most patients who undergo routine ablation procedures.

A statement about RCA states that at the conclusion of the procedure, the access sheaths are pulled, and the patient is put at bed rest for four or more hours.  During this period, the patient is clinically monitored carefully to make certain there have been no access or other types of complications. Depending upon the nature of the procedure, the patient may be admitted to the hospital overnight for observation or discharged later the same day.(2)

A 2012 study (3) presented their experience with same-day discharge in a group of their patients who have undergone catheter ablation. 223 patients were actually discharged on the same day of catheter ablation (56% of 401 overall ablation procedures): 114 atrial flutter (AFL) and 109 supraventricular tachycardia.  The study concluded that same day discharge can be safely performed in most patients undergoing catheter ablation for routine arrhythmias.  This may result in a significant impact on daily practice in terms of both organizational improvement and subjective benefit for the patients.

The health plan acted reasonably with sound medical judgment and in the best interest of the patient. 

The carrier's denial of coverage for the inpatient hospital services is upheld.  The medical necessity is not substantiated.