Appeal type: Medical necessity
Decision: Upheld

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

The patient has a past medical history significant for hypertension, hyperlipidemia, diabetes, and morbid obesity and presented to the hospital with a three-day history of dyspnea, which was associated with exertion, palpitations, and chest tightness. The patient stated that her symptoms were worsening, and this prompted her to seek medical attention. The patient denied a fever, cough, nausea, vomiting, or diarrhea. She reported a previous history of marijuana and cocaine abuse but stated that she does not use illicit substances anymore.
The initial evaluation in the emergency department included a chest x-ray that showed no acute pulmonary disease. The electrocardiogram (EKG) demonstrated atrial flutter with a ventricular rate of 125 beats per minute (bpm). The patient was treated with intravenous Cardizem, and a subsequent EKG was interpreted as atrial fibrillation, but the heart rate was 82 bpm.
When the patient was seen by the admitting physician, her temperature was 99 degrees Fahrenheit (F), heart rate 88 beats per minute (bpm), respiratory rate 20 breaths/minute, and oxygen saturation 99% on room air.
The patient was awake and alert and in no distress. The head, eyes, ears, neck, throat (HEENT) exam was within normal limits. The lungs were clear to auscultation without wheezes, rales, or rhonchi. She had an irregularly irregular heart rhythm. The rest of the physical exam was unremarkable.
Laboratory evaluation revealed that her brain (or B-type) natriuretic peptide (BNP) was 414. The sodium was 141, potassium 4.2, chloride 107, bicarbonate 24.4, blood urea nitrogen (BUN) 19, creatinine 0.83, and glucose 121. The magnesium was normal. Troponin was normal. The white blood cell count was 7.52, hemoglobin 13.7, hematocrit 41.7, and platelets 305. Liver function tests were within normal limits. D-dimer was minimally elevated at 0.52.
The patient was admitted to the hospital with a new onset of atrial fibrillation, and also atrial fibrillation with a rapid ventricular response, diabetes mellitus.
In the hospital, the patient was seen by a cardiologist who stated that after the patient received Cardizem, she converted back into the normal sinus rhythm. The cardiologist recommended initiation of treatment with the blood thinner Xarelto, oral Cardizem, as well as an outpatient stress test and 2 dimensional (D) echocardiogram. On the day after admission, the patient appeared asymptomatic, therefore she was discharged home in stable clinical condition with recommendations for outpatient follow-up.
At issue is the medical necessity of an inpatient stay.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
The review of the medical records demonstrated that even though the patient came to the hospital and was diagnosed with atrial fibrillation with rapid ventricular response, she remained hemodynamically stable and had no signs of myocardial ischemia. The atrial fibrillation was not associated with syncope, heart failure, altered mental status. There was no evidence that atrial fibrillation was the result of drug toxicity. The patient did not require long-term administration of intravenous medications for heart rate control, since she converted back to normal sinus rhythm very quickly. Her symptoms also resolved very quickly, as was mentioned in the notes. Taking into consideration all of this information, care could have been provided at a lower level than inpatient.
 Overall, this patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. 
Neither the severity of the patient's condition nor the complexity of the services provided rose to the level of acute inpatient care. The admission for observation was justified.