Appeal type: Medical necessity
Decision: Upheld

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

This patient presented to the emergency department complaining of rapid heart rate. His medical history was remarkable for hypertension. His blood pressure was 152/97 millimeters of mercury (mmHg) with a heart rate of 109 beats/minute. His room air oxygen saturation was 99%. On physical exam his heart rate was rapid and irregular. An electrocardiogram showed atrial fibrillation with a ventricular rate of 142 beats/minute.  He was treated with two doses of intravenous diltiazem and with an oral dose of diltiazem and admitted to the hospital. Oral metoprolol was prescribed. An electrocardiogram performed at approximately 11 PM on the same day showed sinus tachycardia. On the next day the patient remained in sinus rhythm and was discharged. 
An 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 acute ischemia or decompensated heart failure. He was not at high short-term risk for thromboembolism. For patients presenting with acute AF, the safety of lower 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." An inpatient level of care was not medically necessary for management of this hemodynamically stable patient whose rhythm converted to sinus within hours of his presentation. The patient could have received treatment at a lower level of care.