Cardiac/Circulatory Problems/chest pain.
inpatient admission.
The health plan denied the requested inpatient admission as not medically necessary.
The health plan's determination is upheld.

No medical records were provided for review. The following information was obtained from case notes. This woman presented to the emergency department (ED) complaining of chest pain, palpitations and dizziness. She had just been discharged from the hospital the day prior after undergoing an appendectomy for acute appendicitis. Per the information provided her heart rate was in the 170s beats per minute (bpm) when she was seen in triage. Her ED vitals included a blood pressure of 104/51 millimeters of mercury (mmHg) with a heart rate of 105 beats/minute. An electrocardiogram showed atrial fibrillation with a rapid ventricular rate. The patient was treated with intravenous fluid and Heparin and was admitted to the hospital. A transesophageal echocardiogram was performed. Presumably, this was followed by electrical cardioversion; however, this was not documented in the information provided. The patient was discharged.
The medical necessity for an inpatient admission is at issue.

Based on the limited information provided, I uphold, in whole, the determination that an inpatient level of care was not medically necessary.

No. Based on the limited information provided, an inpatient level of care was not medically necessary.
This patient presented with atrial fibrillation (AF) with a rapid ventricular rate. She was hemodynamically stable. The information provided does not mention any evidence of ischemia, decompensated heart failure, structural heart disease or high short-term risk for thromboembolism. For stable patients presenting with acute AF, the safety of observation level care or discharge to home with close follow-up has been well demonstrated. As stated by Lin et al, "There is growing evidence to suggest that outpatient management is a safe and effective alternative to hospital admission for the management of many patients with acute AF or atrial flutter. Protocols for early rhythm control, clinical decision rules to guide the decision to initiate antithrombotic therapy, and low molecular weight Heparin and direct oral anticoagulants have reduced the need for acute inpatient hospitalization." Likewise, Conti et al, based on an observational study of 3475 patients concluded, "In patients with AF, beyond the standard approach, the novel organization with an additional intensive observation unit for early pharmacological interventions and an outpatient clinic for elective treatment and short-term follow-up significantly reduced admission irrespective of independent predictors of hospitalizations."