Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial fibrillation.
Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.
The denial is upheld. 

This is a female patient who was brought to the Emergency Department (ED), by ambulance, because of an episode of chest tightness and palpitations. The patient admitted drinking alcohol and using crack cocaine just prior to this episode. According to the Emergency Medical Service (EMS) report the patient was found to be in atrial fibrillation with a rapid ventricular response. The patient was given diltiazem and her rhythm converted to normal sinus rhythm. The patient had a history of hypertension and paroxysmal atrial fibrillation (AF), and reported only intermittent compliance with her medication. The patient reported that she now felt well and all her symptoms resolved. There is increasing evidence that most patients with recent-onset AF or atrial flutter (AFL) can be safely managed in the ED without the need for hospital admission.1 
The newer CHA2DS2-VASc (congestive heart failure, hypertension, age >= 75 years, diabetes mellitus, stroke or transient ischemic attack (TIA), vascular disease, age 65 to 74 years, sex category) score also would indicate, for patients such as this one, that long term anticoagulation was necessary. For stable patients with recent-onset AF/ AFL, a strategy of either rate control or rhythm control could be selected based on multiple factors including the duration of AF and the severity of symptoms. Adequate follow-up of patients with recent-onset AF/AFL is recommended to identify structural heart disease and evaluate the need for long-term antithrombotic or antiarrhythmic therapy.2

To address potentially preventable hospital admissions and prolonged length of stay, an AF treatment pathway was co-developed by physicians from the cardiac electrophysiology service and the department of emergency medicine at a University Medical Center. The impact of this AF pathway on patient outcomes was evaluated with a prospective, observational study that was conducted. The primary study outcome was the rate of hospital admission. The 94 patients treated according to the AF pathway during the study period were less likely to be admitted than the 265 patients who received routine care. In conclusion, utilization of a multidisciplinary AF pathway resulted in a 5-fold reduction in admission rate and >2-fold reduction length of stay for admitted patients.3

In this case, this patient has a history of paroxysmal atrial fibrillation and presented to the ED with an episode of atrial fibrillation with a rapid ventricular response, which was related to ingestion of alcohol and recent use of cocaine. The patient converted back to normal sinus rhythm, prior to reaching the ED, after being given oral diltiazem. As per literature review, hospital admission was not medically necessary for this patient. The patient was hemodynamically stable and asymptomatic by the time she arrived to the hospital. The patient was not hypoxic and was stable on physical exam. The patient's care could have been safely provided in the observation status and with close follow-up as outpatient. 

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

The medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial should be upheld.