Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient presented to the emergency department (ED) via Emergency Medical Services (EMS) complaining of two hours of intermittent chest pain and palpitations. In route to the ED he was found to be in atrial fibrillation with a rapid ventricular rate and was treated with intravenous diltiazem and fluids. His medical history was remarkable for coronary artery disease with multiple percutaneous coronary interventions, hypertension, hyperlipidemia, cigarette smoking and morbid obesity. He admitted to noncompliance with his prescribed medications.
In the ED his heart rate was initially 140 beats/minute and an electrocardiogram showed atrial fibrillation with a ventricular rate of 154 beats/minute. There were no acute changes. The patient received intravenous and oral diltiazem and his rhythm converted to sinus. The first blood pressure reported from the ED was 119/78 millimeters of mercury (mmHg). His heart rate at that time was 74 beats/minute. His serum troponin I level was mildly elevated at .049 nanograms/milliliter (ng/ml). A chest x-ray showed no acute pathology. His brain (or B-type) natriuretic peptide (BNP) level was normal.
The patient was admitted to the hospital. His serum troponin level normalized. His oral beta-blocker was adjusted. An echocardiogram showed normal left ventricular systolic function and grade 2 diastolic dysfunction. The patient remained in sinus rhythm and discharge was planned. However, he developed low back pain with lower extremity weakness and tingling and the discharge was canceled. He had no acute bowel or bladder changes. He had difficulty walking due to pain. He was treated with acetaminophen, duloxetine and gabapentin. A magnetic resonance imaging (MRI) scan showed a small central/left paracentral disc herniation at lumbar (L) 5-sacral (S) 1 The patient was seen by a neurologist who recommended tizanidine for pain control. He was seen by a rehabilitation specialist who recommended transfer to a short-term rehabilitation facility (STR). However, the patient initially indicated he preferred to go home and participate in outpatient physical therapy. Tizanidine was unavailable and Baclofen was prescribed. He continued to complain of pain and agreed to STR. He remained hospitalized while awaiting insurance approval. He was transferred to a rehabilitation facility. The medical necessity for an inpatient stay is under review.

Based on the documentation provided an inpatient level of care was not medically necessary.
This patient presented with acute atrial fibrillation (AF) with a rapid ventricular rate. He was hemodynamically stable, he was not in decompensated heart failure, had no evidence of significant structural heart disease and was not at high short-term risk for thromboembolism. His rhythm converted to sinus shortly after his presentation. While his serum troponin level was minimally elevated, there was no significant delta troponin. Troponin elevation in the setting of acute AF is common, even in the absence of underlying coronary artery disease and is not necessarily indicative of acute coronary syndrome (ACS). In this case, no specific treatment for possible ACS was deemed necessary.
For stable patients presenting with acute 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 h 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."
Given this patient's known coronary artery disease and initial mild troponin elevation, admission for observation was appropriate. However, this did not require an inpatient level of care.
The patient was deemed stable for discharge from a cardiac standpoint. He remained hospitalized for management of his back pain and while awaiting transfer to a rehabilitation facility. There was no evidence of an acute neurosurgical emergency, such as bowel or bladder symptoms, progressive neurologic deficit or suspicion of verterbral osteomyelitis or malignancy. The patient did not require intravenous medication for pain control. Based on the documentation provided, continued inpatient care for management of his pain was not medically necessary.