Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial Fibrillation

Treatment: Inpatient hospital admission

The insurer denied the inpatient hospital admission.

The denial was upheld.  

This is a female patient who presented to the Emergency Department (ED) complaining of palpitations and dizziness. She has a history of hypertension. Her presenting vital signs include blood pressure (BP) 127/85, pulse 87, temperature 97.3, respirations 21 and oxygen saturation 98%.  Her initial electrocardiogram (EKG) showed atrial fibrillation with a heart rate in the 160s. She was giving Cardizem 20 mg intravenous (IV) which resulted in a decrease in her BP and heart rate. There are no abnormalities described on her physical exam. It was reported that while being evaluated by Cardiology her rhythm spontaneously converted to sinus tachycardia; she was admitted to the telemetry unit. A repeat EKG was done that revealed atrial fibrillation.  An echocardiogram was done that showed hyperdynamic left and right ventricle function. After a period of medical stability, the patient was discharged home.

Atrial fibrillation (AF) is the most common arrhythmia managed by emergency physicians.  There is increasing evidence that most patients with recent-onset AF or atrial flutter (AFL) can be safely managed in the emergency department (ED) without the need for hospital admission.(1) The priorities for ED management of recent-onset AF/AFL include rapid assessment of potential hemodynamic instability and identification and treatment of the underlying or precipitating cause.  A careful evaluation of the patient's history should be performed to determine the time of onset of the arrhythmia.  All patients should be stratified using a predictive index for the risk of stroke.  For stable patients with recent-onset AF/AFL, a strategy of either rate control or rhythm control could be selected based on multiple factors including the duration of AF and the severity of symptoms.  

Management of atrial fibrillation (AF) in the Emergency Department (ED) is variable because of the absence of universally adopted treatment guidelines.  To address potentially preventable hospital admissions and prolonged length of stay, an AF treatment pathway was co-developed by physicians from the cardiac electrophysiology service and the department of emergency medicine at a University Medical Center.  The impact of this AF pathway on patient outcomes was evaluated with a prospective, observational study conducted in a single tertiary care center from July 1, 2013, to June 30, 2014.  The primary study outcome was the rate of hospital admission.  

An Emergency Department (ED) observation unit protocol for the management of acute onset atrial fibrillation was compared with routine hospital admission and management.  Adult patients presenting to the ED with atrial fibrillation of less than 48 hours' duration without hemodynamic instability or other comorbid conditions requiring hospitalization were enrolled. Participants were randomized to either ED observation unit care or routine inpatient care.  The ED observation unit protocol included pulse rate control, cardiac monitoring, reassessment, and electrical cardioversion if atrial fibrillation persisted.  Patients who reverted to sinus rhythm were discharged with Cardiology follow-up within 3 days, whereas those still in atrial fibrillation were admitted.  

The health plan acted reasonably with sound medical judgment in the best interest of the patient; the telemetry-monitored level of inpatient hospital care was not medically necessary.

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