Diagnosis: Atrial fibrillation
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld.

This is an adult that presented to the hospital complaining of palpitations for several hours. Past medical history was significant for a recent asthma exacerbation requiring treatment with oral prednisone. Upon arrival, an electrocardiogram (ECG) showed atrial fibrillation with rapid ventricular response. The ST-T waves (intervals on an ECG) were normal; the patient was tachycardic with a pulse of 145. The blood pressure (BP) was markedly elevated (202/111) with an oxygen saturation on room air of 99%(percent). Repeat BP was mildly elevated 150s/90s. The physical exam revealed no positive findings other than an irregular rapid pulse. Serum blood testing revealed an elevated white blood cell count of 17. The troponin was normal. The patient was admitted to the hospital and treated with Cardizem and anticoagulant therapy. Later she underwent a successful transesophageal echocardiogram with cardioversion X1. The Echocardiogram showed normal left ventricular function. After sinus rhythm was restored, she was released with follow up.

This patient presented with new onset atrial fibrillation and was hemodynamically stable. The initial hypertension improved within minutes and there was no evidence of an acute cardiac event or uncontrolled tachycardia. Later that day she underwent an uncomplicated electrical cardioversion. As summarized in Up to Date, such patients can be managed without the need for an acute inpatient admission.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for inpatient admission is not substantiated.