Appeal type: Medical necessity
Decision: Overturned in Part

Cardiac/Circulatory Problems - Congestive Heart Failure/CHF
Inpatient Hospital

The patient has a history of hypertension, chronic kidney disease, and heart failure with reduced ejection fraction, polysubstance abuse and a non-ST segment elevation myocardial infarction due to cocaine abuse. He presented to the emergency department complaining of one week of orthopnea, dyspnea and lower extremity edema. He reported noncompliance with his medical regimen. His blood pressure was 146/105 millimeters of mercury (mmHg) with a heart rate of 86 beats/minute. His respiratory rate was 16/minute with a room air oxygen saturation of 97%. Physical exam was remarkable for distant breath sounds and lower extremity edema. His serum creatinine level was 1.41 milligrams per deciliter (mg/dl), which was his baseline. His brain natriuretic peptide (BNP) level was markedly elevated at 2541 pg/ml. There were no acute ischemic electrocardiographic changes. The QT interval was prolonged. His troponin level was minimally elevated. Urine toxicology was positive for cocaine.
Chest x-ray showed mild interstitial edema. The patient was treated with intravenous furosemide and admitted to the hospital under observation status for management of decompensated heart failure. An echocardiogram showed a left ventricular ejection fraction of 18%. The patient complained of continued dyspnea. His respiratory rate was 18/minute with a room air oxygen saturation of 98%. Intravenous furosemide was continued. His status was changed to inpatient. The patient reported dyspnea with minimal exertion. Jugular venous distension was noted. Intravenous furosemide was continued. The patient complained of dyspnea. He was mildly tachypneic. His weight had increased compared to the day prior and jugular venous distension was noted. Intravenous furosemide was continued. The patient had no complaints of dyspnea. His chest was clear. He was switched to oral furosemide. Discharge was recommended; however, the patient refused to be discharged. The patient decided to appeal his discharge. He finally agreed to discharge. Medical necessity for an inpatient admission is at issue.


The health plan's determination is overturned, in part. 

In part. An inpatient admission was medically necessary from the first day of admission until the fifth day.
This patient, with a severely reduced left ventricular ejection fraction, presented with acute decompensated heart failure. His serum troponin level was mildly elevated, a high risk feature. His BNP was markedly elevated. BNP values in the range of this patients have been associated with 2.23-fold increase in in-hospital mortality compared with levels in the lowest quartile (less than [<] 430 pg/mL), even after adjustment for potential confounders and regardless of ejection fraction. In addition, the patient did not have an adequate response to emergency department and observation level of care. Five days after presentation, he continued to complain of dyspnea, was mildly tachypneic and had jugular venous distension and an increase in his weight, despite intravenous diuretic therapy. In should be noted, however, that by the following day there was no longer any objective evidence of acute heart failure decompensation. From the records provided, it does not appear as if there was a medical reason for continued hospitalization from that day onward.