Diagnosis: Atrial Fibrillation
Treatment: Inpatient Hospital
The insurer denied the Inpatient Hospital Stay.
The health plan's determination is overturned.

This is a male patient with a history of seizures, atrial fibrillation, status post cardioversion, cardiomyopathy (ejection fraction (EF) 30 percent (%) and alcohol abuse (1 pint of alcohol (ETOH) 3-4 times per week) who presented to the emergency room with dyspnea and weakness. He was noted to have rapidly conducted atrial fibrillation. He was transferred and admitted to inpatient telemetry. His heart rate was 135 beats per minute (bpm) in atrial fibrillation. He was treated with intravenous digoxin and intravenous heparin. Electrophysiology was consulted for possible cardioversion. An echocardiogram (ECHO) was performed showing severe global left ventricular hypokinesis. Coreg was restarted for rate control and cardiomyopathy. He was started on Entresto, spironolactone and a sodium glucose co-transporter 2 (SGLT2) inhibitor. There was a plan for a transesophageal ECHO and electrical cardioversion. However, the patient left against medical advice (AMA). At issue is the medical necessity of an inpatient stay.

The requested service of inpatient admission is medically necessary for this patient.
The patient meets criteria for inpatient admission. He does have cardiomyopathy, possibly ETOH-induced, and presented (was transferred) with atrial fibrillation with rapid ventricular rates. After 24 hours, he remained with uncontrolled ventricular rates in atrial fibrillation (AF) (120s-140s on telemetry, per progress notes). Per Milliman guidelines, inpatient admission is indicated for patients with atrial fibrillation who have hemodynamic instability, with one indication being persistent uncontrolled ventricular rates in atrial fibrillation. That is the situation for this patient. He required additional hospitalization for ventricular rate control and there was plan for this with transesophageal echocardiogram (TEE) and cardioversion. Other indications for continued hospitalization included severe hypomagnesemia, less than (<) 1. He left against medical advice prior to completion of treatment.
Inpatient admission is indicated, per standard guidelines, including American College of Cardiology (ACC)/American Heart Association (AHA) (reference provided with initial review). The guidelines indicate that cardioversion may be urgently needed for patients with new onset AF and conditions including intractable ischemia, hemodynamic instability, or inadequate rate control. That is the situation for this patient, with inadequate rate control and congestive heart failure (CHF) in the setting of AF.