Diagnosis: Atrial Fibrillation.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a female with a past medical history significant for hypertension (HTN), atrial fibrillation (A. fib), arthritis, facial paralysis, not on any beta-blocker due to prior history of bradycardia. She presented to the emergency room with increasing lethargy and was found to have atrial fibrillation with rapid ventricular rate, at 147 beats per minutes. The patient was given intravenous metoprolol and started on oral metoprolol for rate control. As the patient had prior history of bradycardia and suspected tachy-brady syndrome, she was admitted to telemetry for monitoring during initiation of beta-blocker therapy. She was anticoagulated with low dose apixaban. The patient tolerated the beta-blocker therapy and was discharged home on this dose with rate control.

Yes, the proposed inpatient admission was medically necessary.

The patient presented with uncontrolled atrial fibrillation and required rate control for management of her arrhythmia. She had a prior history of bradycardia, a relative contraindication for the planned beta-blocker therapy. It would be unsafe to initiate a beta-blocker in this patient with advance age, full anticoagulation, risk for significant bradycardia or pause on beta-blocker therapy in a lower level of care without adequate monitoring. Therefore the requested inpatient admission was medically necessary in this clinical setting.