Diagnosis: Atrial Fibrillation
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The determination is upheld.

This is a male patient who presented to the hospital for a scheduled catheter ablation of persistent atrial fibrillation. The procedure was uncomplicated. Post-procedure the patient was admitted to the hospital. He remained stable overnight. His rhythm converted from sinus to atrial fibrillation with a controlled ventricular rate. He denied associated chest pain, dyspnea or palpitation. His rhythm was electrically cardioverted to sinus and the patient was discharged. The medical necessity for an inpatient admission is at issue.

Based on the documentation provided, an inpatient level of care was not medically necessary.

This patient underwent a transcatheter pulmonary vein isolation (PVI) procedure for persistent 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 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 overnight observation post-procedure. This patient's procedure was uncomplicated, and he was hemodynamically stable. He had an episode of atrial fibrillation with a controlled ventricular rate the morning after the procedure that was electrically converted to sinus without complications. While overnight observation was reasonable in this situation, the records provided do not indicate that an inpatient level of care was medically necessary.