Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial Fibrillation
Treatment: Inpatient Hospital Stay

The insurer denied Inpatient Hospital Stay.  The determination is upheld.

This male patient presented to the emergency department complaining of palpitations. His medical history was remarkable for paroxysmal atrial fibrillation, hypertension, type 2 diabetes, obstructive sleep apnea, morbid obesity and recent bariatric surgery.  His serum troponin level was normal. A chest x-ray showed no acute pathology. Thyroid function tests suggested central hypothyroidism. The patient was admitted to the hospital for management of his atrial fibrillation. He was treated with his previously prescribed metoprolol and Multaq. These medications were held due to bradycardia. The patient had no complaints. His ventricular rate ranged from 59-120 beats/minute. Transesophageal echocardiography and electrical cardioversion were scheduled for the next day. However, the patient's rhythm had converted to sinus spontaneously. He was discharged. The medical necessity for an inpatient admission is at issue.
Based on the documentation provided an inpatient level of care was not medically necessary.
This patient presented with acute atrial fibrillation (AF). He was hemodynamically stable, there was no evidence of acute ischemia, he was not in decompensated heart failure, had no evidence of structural heart disease and was not at high short-term risk for thromboembolism. 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% [percent]) 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."