Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atrial Fibrillation 
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is overturned

This geriatric patient presented to the hospital complaining of palpitations and dyspnea. Past medical history was significant for hypertension, diabetes and testicular cancer. Upon presentation to the hospital the patient had a pulse of 140 and a blood pressure of 116/82. Physical exam revealed an irregular heart rhythm. An electrocardiogram (ECG) revealed atrial fibrillation at a rate of 140 and single premature ventricular contractions (PVCs). Serum blood testing revealed normal thyroid function studies (TSH [thyroid stimulating hormone] 2.19) and no elevation in troponin. The patient was admitted for observation and treatment of Atrial Fibrillation (AF) with Rapid Ventricular Response (RVR). An echocardiogram demonstrated a severely depressed Left Ventricular Ejection Fraction (LVEF) of 26-30% (percent). A transesophageal echocardiogram with subsequent cardioversion failed to restore sinus rhythm. The patient was monitored on cardiac telemetry while being loaded on amiodarone therapy. Following several days of amiodarone loading, repeat cardioversion successfully restored sinus rhythm. The patient was discharged home on amiodarone and oral anticoagulant therapy. 

The health plan did not act reasonably with sound medical judgement and in the best interest of the patient. This patient presented with symptomatic atrial fibrillation with rapid ventricular rates and a severely depressed LVEF on the echocardiogram. Acute inpatient admission was necessary to treat this patient and ensure that the patient was on appropriate medical therapy for atrial fibrillation, while monitoring on cardiac telemetry for bradycardia. Patients presenting with atrial arrhythmia and ventricular rates up to 130 require acute therapy and further monitoring to ensure that medications control heart rate and rhythm without producing significant bradycardia. An analysis of 68 million Medicare patients admitted to the hospital for atrial fibrillation over a fifteen-year period demonstrated an average length of stay of 3 days. This analysis also demonstrated decreased mortality and readmission rates following admission to the hospital. The current standard of care is consistent with hospital admission when patients present with symptomatic rapidly conducted atrial fibrillation. This patient failed to maintain sinus rhythm following cardioversion and was treated with amiodarone therapy. The American Heart Association and American College of Cardiology Guidelines for the management of atrial fibrillation recommend careful telemetry monitoring for patients treated with class III antiarrhythmic agents as QT (interval on an ECG) prolongation can lead to ventricular arrhythmia and even sudden cardiac death. In conclusion, acute inpatient admission was medically necessary in this case.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient admission is substantiated.