Diagnosis: Atrial Fibrillation.
Treatment: Hospital Admission.

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

At issue is the case of a gentleman that presented to the hospital for elective left atrial catheter ablation to treat atrial fibrillation. Past medical history was significant for hypertension and symptomatic atrial fibrillation. He underwent electrophysiologic (EP) study with pulmonary vein electrical isolation and cavotricuspid isthmus ablation. The intraoperative and postoperative course were uncomplicated, and the patient was discharged the following day.

In this case, there were no clinical reasons for hospital admission, and the patient could safely be managed at a lower level of care. In two multicenter registry studies looking at healthcare utilization after EP study catheter ablation, more than 80% of patients undergoing ablation were hospitalized for a single day, regardless of age or co-morbidity.(1) Another study demonstrated that patients undergoing atrial fibrillation ablation procedures could be safely discharged on the same day.(2) The current standard of care in an uncomplicated atrial fibrillation ablation is to manage patients at a lower level of care. In conclusion, hospital admission was not medically necessary.

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

The insurer's denial of coverage for the hospital admission is upheld. Medical necessity is not substantiated.