Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atrial Fibrillation. 
Treatment: Hospital admission. 
The insurer denied coverage for the hospital admission. 
The denial is overturned. 

The insurer has denied coverage for the full hospital admission as not medically necessary. In a Final Adverse Determination letter, they stated that the patient presented to the hospital with complaints of atrial fibrillation. There were no severe problems warranting a full hospital admission. The requested admission is denied based on Milliman Care Guidelines using the guideline of Atrial Fibrillation (ORG: W0114). 

A Cardiologist is appealing on behalf the hospital. In an appeal letter it is stated that the patient is morbidly obese. The patient has a history of atrial fibrillation, hypertension, sleep apnea, lymphedema, and diabetes. The patient presented to the emergency room (ER) from the Cardiologist's office with complaints of a rapid cardiac rate and hypotension. An electrocardiogram (EKG) revealed supraventricular tachycardia. The care plan consisted of telemetry monitoring, intravenous (IV) fluids, IV metoprolol, IV diltiazem, IV Digoxin, Multaq, Famotidine, Verapamil, and Amiodarone. The patient was discharged. The requested admission was warranted for this patient who presented with a rapid heart rate. 

This is the case of a patient that presented to the hospital with complaints of fatigue, worsening pedal edema, elevated heart rate and low blood pressure. Past medical history was significant for paroxysmal atrial fibrillation status post remote catheter ablation, morbid obesity, obstructive sleep apnea, and lymphedema. On arrival to the hospital the patient was tachycardic with a heart rate of 167 and blood pressure (BP) was 98/68.  Physical exam was significant for pedal edema. 12 lead electrocardiogram (EKG) demonstrated atrial flutter with 2:1 conduction and a ventricular rate of 168bpm. Serum blood testing was significant for an elevated high sensitivity troponin (29) and an elevated serum creatinine (1.9). The patient was admitted to the hospital but could not be treated with atrioventricular (AV) nodal blocking agents due to relatively low BP. The patient ultimately reverted to normal sinus rhythm and was discharged on amiodarone therapy. 

The health plan did not act reasonably. Admission for monitoring and treatment was medically necessary. Patients presenting with atrial arrhythmia with rapid ventricular rates require acute therapy and further monitoring to ensure that medications control heart rate and rhythm without producing significant bradycardia (1). An analysis of 68 million Medicare patients admitted to the hospital for atrial fibrillation over a fifteen-year period demonstrated an average length of stay of 3 days (2). This analysis also demonstrated decreased mortality and readmission rates following admission to the hospital. The current standard of care is consistent with hospital admission when patients present with symptomatic rapidly conducted atrial fibrillation. This patient presented to the hospital with atrial flutter and rapid ventricular rates. Treatment with AV nodal blocking agents was not possible due to relatively low blood pressure. In patient telemetry monitoring during titration of antiarrhythmic therapy was required. In conclusion, full hospital admission was medically necessary. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the full hospital admission is substantiated.