Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory-Problems
Treatment: Inpatient hospital stay
The plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

This patient presented to the emergency department (ED) via Emergency Medical Services (EMS) complaining of palpitations. An electrocardiogram performed by EMS showed atrial fibrillation with a ventricular rate of 180 beats/minute. Diltiazem 20 milligrams (mg) intravenously was administered. The patient's medical history was remarkable for Marfan syndrome, alcohol abuse, and atrial fibrillation, atrial flutter and atrial tachycardia. He had previously undergone two catheter ablation procedures. In the ED, his blood pressure was 115/77 millimeters of mercury (mmHg) with a heart rate of 147 beats/minute. His room air oxygen saturation was 99% (percent). An electrocardiogram showed atrial fibrillation without acute ischemic changes. The patient's serum troponin and brain (or B-type) natriuretic peptide (BNP) levels were normal. He received another dose of intravenous diltiazem and was admitted to the hospital. Oral diltiazem and intravenous metoprolol, as needed, were prescribed. The patient's rhythm spontaneously converted to sinus. An echocardiogram showed normal left ventricular systolic function. The patient was discharged.

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 ischemia, he was not in decompensated heart failure, had no evidence of structural heart disease and was not at high risk for thromboembolism. For patients presenting with acute AF, the safety of a lower level of care 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%) managed with this approach spontaneously cardioverted to normal sinus rhythm within 48 h (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." While an admission for observation and monitoring for ventricular rate control was reasonable in this instance, it did not require an inpatient level of care. The patient could have been treated at a lower level of care.