Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute on chronic congestive heart failure exacerbation.

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld. 

This is a male patient who had persistent atrial fibrillation. The patient's pertinent past medical and past surgical history includes coronary artery disease (status post coronary artery bypass graft), systolic heart failure with reduced left ventricular ejection fraction, hypertension, dyslipidemia, hypothyroidism, obesity, and obstructive sleep apnea. His home medications include: Eliquis, Levothyroxine, Lipitor, Metoprolol Succinate ER, Entresto and torsemide. His metoprolol ER was increased, but he still complained of shortness of breath, dyspnea on exertion, fatigue and palpitations with occasional orthopnea. In light of his symptoms, the patient came to the hospital for an elective cardioversion. The patient was admitted to Telemetry/Stepdown post cardioversion for acute on chronic congestive heart failure exacerbation and possible antiarrhythmic drug load. Strict intake and output and an echocardiogram were ordered. Toprol XL was decreased. The patient was started on intravenous Lasix and was continued on Entresto and Eliquis. The patient declined morning blood work and an echocardiogram. He was instructed to continue his medications, to follow a low salt, low fat diet, and fluid restrictions to 1 liter a day. The patient was discharged the day after admission with outpatient follow up. 

A study in the Annals of Emergency Medicine reviewed the safety and success of emergency department cardioversion and discharge of patients with recent onset atrial fibrillation. The study concluded that cardioversion and immediate discharge of patients who present to the Emergency Department (ED) with acute atrial fibrillation appears to be both safe and effective. 

Atrial fibrillation (AF) is the most common arrhythmia managed by emergency physicians. 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. Management of AF in the ED is variable because of the absence of universally adopted treatment guidelines. 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. 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 (16% vs 80%, p <0.001).  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.

This patient presented to the ED with AF and shortness of breath. He was known to have coronary artery disease, previous coronary artery bypass graft (CABG) and decreased left ventricular ejection fraction.  He was successfully converted back to normal sinus rhythm. Following return of his cardiac rhythm to normal sinus, the patient remained asymptomatic and had normal vital signs and normal physical examination. Literature clearly documents that a hospital admission is not medically necessary for patients who are asymptomatic, have normal vital signs and physical examination and are oxygenating well. The health plan acted reasonably with sound medical judgment in the best interest of the patient. 

The carrier's denial of coverage for the inpatient hospital admission is upheld. The medical necessity is not substantiated.