Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain and Shortness of Breath
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult female. She was hospitalized for CHF (congestive heart failure) exacerbation. She presented to the hospital ED (emergency department) for evaluation of chest pain, shortness of breath, palpitation and leg swelling for the 
prior four to five days. Her past medical history is pertinent for known CHF (congestive heart failure), hypertension, diabetes, herpes, COVID-19, HIV (human immunodeficiency virus), COPD 
(chronic obstructive pulmonary disease) with asthma and morbid obesity. The patient's vital signs were stable: BP (blood pressure) 128/53, HR (heart rate) 79, afebrile, RR (respiration rate) 20 and O2 (oxygen) saturation 98% (percent) on RA (room air). Exam revealed reproducible chest wall tenderness, morbid obesity and 2+ (plus) pitting edema up to her thighs. Troponin panel was negative. EKG (electrocardiogram) showed sinus rhythm with right bundle branch block. Chest xray reported cardiomegaly with tortuous thoracic aorta. Echocardiogram with Doppler showed LVEF (left ventricle ejection fraction) was in normal range. Treatment included IV (intravenous) Lasix, SC (subcutaneous) Lovenox and continuation of her home medications. She improved and 
was discharged to have NST (Non-Stress Test) done as OP (outpatient) with Cardiology.
This is an appeal of the denied claim the requested Acute Inpatient Hospital Stay was medically necessary for this patient.

The Inpatient Hospital Admission was not medically necessary.

Based on the peer-reviewed medical literature and this reviewer's expert medical opinion, the documentation submitted for review do not establish the requested Acute Inpatient Hospital Stay was medically necessary for this patient. According to the MCG (Milliman Care Guidelines) Guidelines titled: Heart Failure (ORG: M-190), inpatient admission was not medically necessary, because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay per the guideline. Criteria for inpatient stay are not met, including documentation of hemodynamic instability, respiratory distress, change in mental status, severe heart failure, cardiac arrhythmias of immediate concern, myocardial ischemia or myocardial infarction, positive troponin not explained by CKD (chronic kidney disease) and CHF (congestive heart failure), hypertension requiring inpatient hospitalization, CVA (cerebrovascular accident), pulmonary embolism, aortic dissection, pneumonia, severe electrolyte abnormalities or any other medical condition or other medical instability or acute care needs for which emergency and observation care have failed or are not considered appropriate and that would require acute inpatient management. In this particular case, there was no clinical decline or inadequate response to treatment which required continuation of the hospital stay past the observation period. The care she received for uncomplicated acute on chronic HFpEF (heart failure with preserved ejection fraction) like in this case, is routinely provided safely and effectively at a lower level of care.