Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems
Treatment: Inpatient hospital
The insurer denied: Inpatient stay
The denial is: Upheld in whole

The patient is a female with a history of hypertension and supraventricular tachycardia. She presented to the emergency department complaining of palpitations, chest tightness and lightheadedness. Her blood pressure was 74/69 millimeters of mercury (mmHg) with a heart rate of 188 beats/minute. Her respiratory rate was 22/minute with a room air oxygen saturation of 100%. Her physical exam was notable for tachycardia and was otherwise unremarkable. An electrocardiogram showed supraventricular tachycardia at a rate of 214 beats/minute. There was inferolateral ST segment depression. The patient's serum troponin and brain natriuretic peptide (BNP) levels were normal. Chest x-ray showed no acute pathology. She was treated with two doses of intravenous adenosine and repeated doses of intravenous diltiazem with continued tachycardia. A repeat electrocardiogram showed atrial fibrillation with a heart rate of 125 beats/minute. Her blood pressure improved to 112/67 mmHg. The patient was then treated with oral diltiazem and enoxaparin and admitted to the hospital for further management of atrial fibrillation. The patient's rhythm had converted to sinus. An echocardiogram was performed and was normal. She was discharged. Medical necessity for an inpatient stay is at issue.

The health plan's determination is upheld, in whole.

An inpatient stay was not medically necessary. This patient presented with supraventricular tachycardia. After treatment with intravenous adenosine and diltiazem she was found to be in atrial fibrillation with a rapid ventricular rate. After initial hypotension, she was hemodynamically stable. There was no evidence of structural heart disease or congestive heart failure. Her BNP and troponin levels were normal. In patients with acute atrial fibrillation (AF), the safety of observation level 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 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."

Based on the the Milliman Care Guideline, Supraventricular Arrhythmias, the patient met none of the criteria for inpatient. The patient could have been treated at a lower level of care status.