Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital. 
The insurer denied Inpatient Stay. 
The denial is upheld. 

The patient is a male with a past medical history significant for hypertension, type 2 diabetes mellitus, dyslipidemia, systolic congestive heart failure (CHF), status post- automatic implantable cardioverter defibrillator (AICD), and tobacco and cocaine abuse who presented to the emergency department with complaints of shortness of breath for 4 days. The patient stated that the shortness of breath led to significant limitations of functional capacity. The shortness of breath was aggravated by exertion and relieved while resting. The patient also complained of orthopnea and paroxysmal nocturnal dyspnea as well as cough with phlegm and runny nose.
At the time of the initial evaluation, the patient was afebrile. Blood pressure was 132/95, pulse rate was 102 beats per minute (bpm), respiratory rate was 18 breaths/minute (min), oxygen saturation was 97% (percent) on room air. The patient was in no acute distress. The head, eyes, ears, neck, throat (HEENT) exam was within normal limits. Lungs exam revealed bilateral crackles. The patient had a pacemaker. There were normal pulses and normal heart sounds. It was noted that the patient had bilateral lower extremity edema.
The laboratory evaluation revealed that white blood cell count was 4.7, hemoglobin was 12.1, hematocrit was 36.2, and platelets were 202. Sodium was 138, potassium was 3.7, chloride was 104, bicarbonate was 26, blood urea nitrogen (BUN) was 16.8, and creatinine was 1.54. His gamma-glutamyl transferase (GGT) was 1130, alkaline phosphatase was 284, aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were normal.
The patient was admitted to the hospital with a diagnosis of acute CHF exacerbation. The admitting physician stated that the patient was grossly noncompliant with medications and lifestyle modifications. At the time of admission, the patient was started on intravenous Lasix. He was continued on medication such as Lipitor, and aspirin. The elevated troponin levels were attributed to CHF exacerbation. The patient was started on insulin. At the time of admission, it was mentioned that the patient had chronic kidney disease and his creatinine was at the baseline. The patient expressed a desire to leave the hospital against medical advice.
At issue is the medical necessity of Inpatient Stay.

The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of Inpatient Stay was not medically necessary for this patient.
The review of the medical records showed no evidence that the patient had hemodynamic instability, acute kidney injury, severe electrolyte abnormalities requiring inpatient care, cardiac arrhythmias of immediate concern, presence of acute decompensated conditions precipitating CHF such as pneumonia, or pulmonary embolism. There was no evidence that the patient had severe pulmonary edema that required invasive or noninvasive assisted ventilation, massive skin edema, intractable pulmonary edema, persistent tachypnea, altered mental status, or acute peripheral ischemia. The patient did not require pulmonary artery catheter monitoring. Overall, this patient remained in stable clinical condition and did not need any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. It was clearly indicated in the progress notes that on the next day after the day of admission that the patient denied any acute complaints and reported that his symptoms were improving. Except for the acute CHF that was the main reason for admission, his other clinical conditions were relatively stable. He had some degree of hyperglycemia at times, which was successfully treated with insulin injections. There was no evidence of glycemic emergencies.
Therefore, the requested health service/treatment of Inpatient Stay was not medically necessary.