Diagnosis: Cardiac/Circulatory Disorders.
Treatment: Inpatient Hospital.
The insurer denied: Inpatient stay.
The denial is: Upheld in whole.

The patient is a male with a history of hypertension, human immunodeficiency virus (HIV) infection. chronic kidney disease, cocaine abuse, cocaine-induced myocardial infarction, paroxysmal atrial fibrillation, and congestive heart failure with reduced ejection fraction. He presented to the hospital for elective catheter ablation of his atrial fibrillation. The procedure was uncomplicated. Post-procedure, the patient was admitted to the hospital. He remained hemodynamically stable. He was treated with ondansetron for emesis. He was discharged. Medical necessity for an inpatient stay is at issue.

The health plan's determination is upheld in whole.

This patient underwent transcatheter pulmonary vein isolation (PVI) procedure for paroxysmal atrial fibrillation. Given the complexity of the procedure, with transseptal punctures, catheter manipulation and ablation within the left atrium, full dose anticoagulation, and the proximity of the ablation lines to the esophagus, the complication rate of this procedure is higher than that of catheter ablations for other supraventricular arrhythmias. Accordingly, despite at least two reports demonstrating the safety of same day discharge after PVI, most electrophysiologists admit patients for a period of monitoring post-procedure. This patient's procedure was uncomplicated, and he was hemodynamically stable. In summary, the patient could have been managed at a lower level of care status. An inpatient stay was not medically necessary.