Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Symptomatic tachycardia.
Treatment inpatient admission.
The insurer denied coverage for inpatient admission.
The denial is overturned.

The patient is female with a past medical history of asthma and obesity, status post cholecystectomy and umbilical hernia repair. She presented to a local urgent care provider with lightheadedness, chest discomfort, presyncope and palpitations. She was diagnosed with new onset atrial fibrillation and was then transferred emergency department (ED). In the ED, she was noted to have persistent palpitations, lightheadedness and belching. Chest x-ray and lab work, including Troponin, was unremarkable. Electrophysiology (EP) was contacted, and they recommended rate control with beta-blocker, anticoagulation with Eliquis, and admission to telemetry. A transesophageal echocardiogram (TEE)/cardioversion was planned if the patient was still in atrial fibrillation at that time, with transthoracic echocardiogram, Eliquis (apixaban), and metoprolol recommended in the interim. She was to be placed nothing by mouth (NPO).

The patient was still complaining of palpitations and a Cardiology consultation was performed. The admission electrocardiogram (EKG) was reviewed and was consistent with atrial fibrillation with rapid ventricular response (134 beats per minute). TEE/Cardioversion was planned, with echo, Eliquis, and increased metoprolol recommended in the interim.

A Cardiology follow-up was done. The patient had felt a return to sinus rhythm the day prior and had no complaints. The patient was asking to go home, which was approved by Cardiology pending echocardiogram results. An echocardiogram performed on that day was unremarkable, with normal left ventricular (LV) function, normal atrial size, and normal valvular function. EP follow-up was performed and orders were placed for initiation of Sotalol; the patient refused Sotalol, preferring to go home and discuss this recommendation with a relative who was a pharmacist. 

This patient did have persistent symptomatic tachycardia at the time of admission, and symptoms did not completely resolve until sinus rhythm was restored. A prolonged (greater than 48 hour) hospitalization was appropriately anticipated and planned for, from the time of her initial evaluation. Initially, this was likely to be necessary in order to perform a TEE/cardioversion, and later for potential Sotalol initiation. 

Consideration of Sotalol appears to have been brief but was clinically reasonable and would have warranted yet an additional 48-72 hours of hospitalization, given a 13.4% (percent) likelihood of adverse cardiac events from its initiation. The patient spontaneously converted to sinus rhythm and then refused Sotalol, both of which were unforeseeable, and both of which enabled discharge earlier than planned. Neither change was relevant at the time of admission, and in fact, both became apparent only after two midnights had already elapsed, making them irrelevant to the opinion that shorter hospitalization under observation status was reasonable. This opinion can only appear valid in retrospect when unforeseeable events are known.

Based on this review, there was sufficient evidence to support that the inpatient hospitalization was medically necessary, both for the planned TEE/cardioversion, and potentially for the initiation of Sotalol. Observation status was not appropriate.

The health care plan did not act reasonably, with sound clinical judgment, or in the best interest of the patient.

The insurer's denial of coverage for the inpatient admission is overturned. Medical necessity is substantiated.