Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Palpitations
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient presented to the emergency department (ED) complaining of exertional dyspnea and palpitations. He also reported chest pain that was chronic following a motor vehicle accident years prior. His medical history was remarkable for hypertension, congestive heart failure and atrial fibrillation. He had left another hospital against medical advice earlier the same day; he had been admitted there for atrial fibrillation with a rapid ventricular rate.
In the emergency department (ED) his blood pressure was 138/86 millimeters of mercury (mmHg). His heart rate ranged from 102-137 beats/minute. His respiratory rate was 18 breaths/minute. His room air oxygen saturation was 99%. On physical exam, he had jugular venous distension. His chest was clear and his heart rhythm was irregular. An electrocardiogram showed atrial fibrillation with a rapid ventricular rate. His brain (or B-type) natriuretic peptide (BNP) level was 647 picograms per milliliter (pg/ml). His serum troponin level was normal. A chest x-ray showed hyperinflation and a possible small right pleural effusion. The patient was admitted to the hospital for management of atrial fibrillation with a rapid ventricular rate and congestive heart failure. He was treated with metoprolol, apixaban and oral furosemide. The patient's ventricular rate ranged from 60-118 beats/minute. Per the physician's note he was euvolemic. An echocardiogram showed a left ventricular ejection fraction of 55%. There was inferolateral hypokinesis. There was mild mitral and aortic regurgitation and mild to moderate tricuspid regurgitation. The patient was discharged. At issue is the medical necessity of an inpatient stay.
Based on the documentation provided an inpatient level of care was not medically necessary.
This patient presented with atrial fibrillation (AF) with a rapid ventricular rate. He was hemodynamically stable, without evidence of acute ischemia, and was not at high risk for thromboembolism. His ventricular rate was controlled with oral metoprolol. For stable patients presenting with acute AF, the safety of a lower level of 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 atrial fibrillation (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."
The patient was also diagnosed with decompensated heart failure. He did not have high-risk features such as systolic blood pressure less than (<) 100 millimeters of mercury (mmHg); electrocardiographic changes consistent with ischemia; acute kidney injury or significant hyponatremia.. He responded well to oral furosemide. Based on his Emergency Heart Failure Mortality Risk Grade score his 7-day mortality risk was low. In stable heart failure patients, such as this patient, without high-risk features, studies have shown that a lower level care is safe and effective, with similar outcomes, including readmission, repeat emergency department visits and 30 day mortality, when compared to those treated as inpatients. Thus, in this instance, an lower level of care would have been sufficient; an inpatient admission was not medically necessary.