Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Congestive heart failure. 
Treatment: Inpatient admission. 

The insurer denied coverage for the inpatient admission. 

The denial is upheld. 

This male patient came to the Emergency Department (ED) with complaints of shortness of breath (SOB) and worsening left lower extremity edema. He reported dysuria and urinary obstruction. He was taking Lasix at home for bilateral lower extremity edema. His medical history is significant for atrial fibrillation (on Coumadin), mitral valve disease, diabetes, hypertension and hyperlipidemia. His laboratory studies revealed an elevated Pro-BNP (pro B-type natriuretic peptide) of 2,215 and elevated white blood cell (WBC) count of 17.3. His past surgical history includes mitral valve repair with a bovine graft. His urinalysis was notable for orange color. He was treated with intravenous (IV) Lasix, IV ceftriaxone, IV magnesium sulfate, aspirin, atorvastatin and Flomax. He was admitted for acute decompensated diastolic congestive heart failure (CHF) exacerbation with urinary tract infection (UTI). A recent echocardiogram revealed a left ventricular ejection fraction (LVEF) of 60%. A note from an ED nurse states that the patient will be admitted to medicine pending bed availability. On physical exam, he was described as in no distress. There is no respiratory distress and he has no rales heard. His vital signs in the ED include temperature 99.1, blood pressure (BP) 120/75, pulse 96, respirations 17 and oxygen saturation 95%; his weight is 236 pounds. His current home medications include aspirin, enalapril, Lasix, glimepiride, linagliptin-metformin, photonix. Results of laboratory studies include WBC 17.3, hematocrit 43.1, sodium 137, potassium 3.9, BUN 20, creatinine 0.83, glucose 160 and troponin was within normal limits. Assessment and plan states that this is a male with a past medical history of obesity, type II diabetes, hypertension, heart failure with preserved ejection fraction and history of mitral valve replacement with a bovine valve. He was directed to come to the ED by his primary care physician and admitted for decompensated heart failure. Urine analysis describes the urine color as orange. There is a small amount of bilirubin and no blood is present, 11-20 white blood cell (WBC) counts were noted and 0-3 red blood cell (RBC) counts were noted. Urine culture was positive for Klebsiella pneumonia. A chest x-ray was done and showed a cardiac valvular prosthesis is present in the mitral position. There is prominence of the pulmonary vessels in the upper lung fields and perihilar markings consistent with congestive failure. Small bilateral pleural effusions are suggested. An EKG showed an ectopic atrial tachycardia, right ventricular hypertrophy versus left posterior fascicular block and ST elevation, lateral injury. The discharge note states that the patient was admitted for a heart failure exacerbation requiring intravenous (IV) diuretics. This was likely triggered by dietary noncompliance. He was started on IV Lasix 80 mg BID (twice daily), which he tolerated well. He also had evidence of a urinary tract infection likely due to an enlarged prostate. He was started on an antibiotic and Flomax and advised to continue these medications at home. His vital signs included temperature 97.8, heart rate 98, respirations 20, oxygen (O2) saturation 97% and blood pressure (BP) 148/88. The patient was described as being morbidly obese and in no acute distress. No murmurs rubs or gallops were appreciated. The patient's lungs were clear at this time. He had no lower extremity edema. It was thought that he was medically stable to go home and would continue taking Lasix 40 mg twice a day, ceftriaxone for three days and Flomax daily. 

This patient presented to the hospital with complaints of shortness of breath and leg swelling consistent with fluid overload, which was thought to be secondary to his diet. The patient was in no distress, normal saturation with no rales heard. Labs showed a normal sodium (Na), creatinine and Troponin. Such patients can be managed with a period of observation followed by close outpatient treatment. There was no need to admit the patient as an acute inpatient. This patient was an ideal candidate for an observation unit. The denial of coverage for this inpatient admission should be upheld. 

The health plan acted reasonably with sound medical judgment and in the best interest of the patient. 

The carrier's denial of coverage for the inpatient hospital admission is not substantiated. The insurer's denial is upheld.