Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Cardiovascular/Arrhythmia/Irregular Heart Rhythm/Atrial Fibrillation.
Treatment: Inpatient stay.
The health plan denied the inpatient stay as not medically necessary. 
The reviewer has upheld the previous determination in whole. 

This patient presented to the emergency department complaining of two hours of palpitations. Past medical history was remarkable for hypertension, paroxysmal atrial fibrillation, and heavy alcohol use. The blood pressure was 181/134 mmHg with a heart rate of 140 beats/minute. The patient  appeared anxious. On physical exam the patient had a rapid, irregular heart rate. An electrocardiogram showed atrial fibrillation with a rapid ventricular rate. There were no acute ischemic changes. Serum potassium level was 3.5 mmol/L. The patient was treated with intravenous fluids, intravenous and oral diltiazem, diazepam, magnesium, and oral potassium and was admitted to the hospital and treated with oral metoprolol. The rhythm converted to sinus. The following day the patient remained in sinus rhythm. An echocardiogram was performed and was unremarkable. The patient was discharged. 

An inpatient level of care was not medically necessary. This patient presented with acute atrial fibrillation (AF), was hemodynamically stable, there was no evidence of ischemia, was not in decompensated heart failure, had no evidence of structural heart disease and was not at high risk for thromboembolism. The rhythm converted to sinus within hours of  presentation. For patients presenting with acute AF, the safety of a lower level 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 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." A lower level of care would have been appropriate in this instance.
The patient also did not meet any of the criteria from Milliman Care Guidelines (MCG) Health Atrial Fibrillation.