Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is: Upheld

The patient is a male who presented to the emergency department (ED) complaining of one day of chest pain and palpitations. His medical history was remarkable for recurrent episodes of atrial fibrillation and electrical cardioversions. His history was also notable for hypertension, heart failure with reduced ejection fraction (30-34%[percent]), single vessel coronary artery disease and morbid obesity. In the ED his blood pressure was 135/97 millimeters of mercury (mmHg) with a heart rate of 142 beats/minute. His room air oxygen saturation was 99%. An electrocardiogram showed atrial fibrillation with a rapid ventricular rate. His serum troponin level was normal. Chest x-ray showed no acute pathology. The patient was treated with intravenous and oral metoprolol. He was admitted to the hospital and was transferred from the ED to the electrophysiology laboratory where he underwent transesophageal echocardiography followed by direct-current (DC) cardioversion of his rhythm to sinus. Per the admission notes, he was admitted with plans for catheter ablation when the schedule allowed. The patient remained in sinus rhythm. He underwent catheter ablation for his atrial fibrillation. The procedure was uncomplicated. He was discharged. Medical necessity for an inpatient hospital admission is under review.

The health plan's determination is upheld.

Based on the documentation provided an inpatient hospital admission was not medically necessary.
This patient presented with atrial fibrillation with a rapid ventricular rate. He was hemodynamically stable. There was no evidence of acute ischemia or decompensated heart failure. His rhythm was electrically converted to sinus without complications and he remained in sinus rhythm throughout his hospital stay. Per the medical record he remained hospitalized awaiting an opening in the electrophysiology laboratory for catheter ablation. The record does not indicate that there was a medical reason that this couldn't be performed on 9/15/22 nor does it indicate that the patient was unable, for medical reasons, to be discharged and return for the procedure once the schedule allowed. Moreover, the record does not document the need for inpatient care post-procedure. Given the complexity of the procedure involved in atrial fibrillation ablation, with transseptal punctures, catheter manipulation and ablation within the left atrium, full dose anticoagulation, and the proximity of the ablation lines to the esophagus, the complication rate is higher than that of catheter ablations for other supraventricular arrhythmias. Accordingly, despite at least two reports demonstrating the safety of same day discharge post-procedure, most electrophysiologists admit the patients for overnight observation post-procedure. This patient's procedure was uncomplicated, and he was hemodynamically stable. Accordingly, while overnight monitoring post-procedure was reasonable, the records provided do not indicate that an inpatient level of care was medically necessary.