Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of Breath and Dizziness.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is upheld.

The patient is an adult male. He was hospitalized for shortness of breath and dizziness. He presented to the hospital ED (emergency department) for evaluation of shortness of breath, chest pain, lightheadedness and dizziness of several weeks' duration. His past medical history is remarkable for atrial fibrillation treated with ablation x2, hypertension, hyperlipidemia, type 2 diabetes and diverticulitis. The patient's vital signs were stable. BP (blood pressure) was 140/79. HR (heart rate) was 89. RR (respiration rate) was 15. Oxygen saturation was 96% on RA (room air). EKG (electrocardiogram) showed atrial fibrillation. Hemoglobin was 10.8. Echocardiogram showed mildly depressed EF (ejection fraction) of 45%. EP (electrophysiology) cardiology recommended possible cardioversion for recurrent symptomatic atrial fibrillation. By the next day, EP (electrophysiology) re-evaluated the patient and felt atrial fibrillation rate was well controlled and recommended pulmonary evaluation for worsening dyspnea and GI (gastroenterology) evaluation for worsening anemia that may explain his presenting complaints. He was discharged to home with arrangements for OP (outpatient) follow up. The acute inpatient hospital stay was denied coverage by the health plan as not medically necessary, 
citing that the patient could have been treated at the Observation level of care. This denial is being appealed.

The Inpatient Hospital Admission was not medically necessary.

Based on the peer reviewed medical literature, the documentation submitted for review do not establish the requested Acute Inpatient Hospital Stay was medically necessary for this patient. According to the MCG (Milliman Care Guidelines) guideline for Atrial Fibrillation (ORG: M-505), criteria for inpatient admission are not met, including hemodynamic instability, myocardial ischemia, syncope, altered mental status, dyspnea or hypoxemia, pulmonary edema, continuous cardiac monitoring that is required for condition causing arrhythmia, such as serious electrolyte abnormality, any underlying medical condition requiring inpatient care like thyrotoxicosis or pneumonia, recent systemic embolic event like CVA (cerebrovascular accident), initiation of antiarrhythmic drug (AAD) therapy for patient at high risk for adverse effects like use of AAD (antiarrhythmic drug) with proarrhythmic potential, low ejection fraction, congenital heart disease, valvular heart disease, prolonged QT interval, significant sinus or AV (atrioventricular) node conduction disease, intolerable symptoms despite optimal OP (outpatient) treatment or elective or urgent cardioversion which cannot be done on an OP (outpatient) basis or during observation care. In this particular case, none of these medically necessary criteria for inpatient stay were met. The care that the patient received, including determining that he was probably not experiencing symptomatic atrial fibrillation after all and recommending outpatient pulmonary and the anemia workups instead, is routinely provided safely and effectively at a lower level of care, such as at the Observation level of care. Therefore, based on the submitted information and the standard of care, the inpatient level of care was not medically necessary for this patient. The patient's hand-written note on the appeal form and letter reports his hospital stay was extended overnight due to findings of IDA (iron deficiency anemia) and hypokalemia, which are routinely managed at a lower LOC (level of care).