Diagnosis: Atrial fibrillation
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a male. He was admitted following an accident with atrial fibrillation and active use of Eliquis. He was weak, had palpitations and felt the care and communication of the initial hospital was inadequate. His work up included history of atrial fibrillation, normal echocardiogram.

Once admitted, the patient denied chest pain, palpitations or dizziness. He arranged transfer per patient's preference. His enzymes were negative. His vital signs were stable. His exam was normal except for known atrial fibrillation.

No, the Inpatient admission was not medically necessary.
Determination of level of care is primarily dependent on the actual care a patient receives, and whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results. It is highlighted in the orders for care.

There was no clinical need for any inpatient level of care. The patient was hemodynamically stable. His atrial fibrillation had a controlled ventricular response, with no evidence of ischemia or infarction. The patient's care, including all testing and treatment, would have been appropriate and safely performed in a lower level of care.

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.