Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Atrial Fibrillation.
Treatment:  Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.  The denial is upheld.  

This male patient has a medical history of hypertension, substance abuse and bipolar disorder. He was brought to the emergency department (ED) for 2-3 days of chest pain with nausea, vomiting and dizziness. While in the ambulance he was noted to be in atrial fibrillation (AF) and given intravenous (IV) Cardizem. The patient is an everyday cigarette smoker. The morning of his admission, he woke up with new onset shortness of breath. Vital signs were stable. Examination revealed lungs with diminished breath sounds and scattered rhonchi, and heart with irregularly irregular rhythm. Laboratory results included elevated D-dimer at 730. His troponins were within normal limits. A computed tomography (CT) angiogram of the chest showed no evidence of pulmonary embolus, mild bibasilar dependent atelectasis, and multiple solid lung nodules. The patient was seen by cardiology for new onset of AF. A chest x-ray showed no acute cardiopulmonary disease. Urine drug screen was positive for barbiturate and benzodiazepine. Nuclear stress test was normal. Echocardiogram showed left ventricular ejection fraction (LVEF) was 45% with possible inferior lateral hypokinesis. His rhythm returned to sinus with resolution of his symptoms. He was discharged on Aspirin and Toprol-XL.

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 ED without need for admission. (1) 

The priorities for ED management include rapid assessment of potential hemodynamic instability 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. If a strategy of rhythm control has been selected, either electrical or pharmacologic cardioversion may be used. Before proceeding to cardioversion in the absence of systemic anticoagulation, physicians must be confident that the duration of AF/AFL is clearly less than 48 hours and that the patient is not at a particularly high risk of stroke.

A study found that 59% of ED visits with a primary diagnosis of atrial fibrillation resulted in hospitalization in the United States (US) compared with 37% in Canada's most populous province. The largest intercountry variation was for patients younger than 65 years: 64% of visits made by these patients resulted in hospitalization in the United States versus 25% in the Canadian cohort. Several Canadian studies have suggested that discharge home is safe. Presumably the younger US patients are being admitted for further testing; however, this can be performed on an outpatient basis (Atzema, et al.)

A statement in the literature states that studies have shown that discharge from the ED is safe for most patients. (Long, et al.)

This patient presented with chest pain and new onset AF. He did not have myocardial infarction or congestive heart failure. He successfully cardioverted back to normal sinus rhythm without intervention. The literature cited clearly documents that hospital admission is not medically necessary for patients who are currently asymptomatic, have normal vital signs and examination, and oxygenating well. 

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

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