Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems/Congestive Heart Failure/CHF
Treatment: Inpatient Hospital Admission
The health plan denied the requested inpatient hospital admission as not medically necessary. 
The health plan's determination is upheld.

This man presented to the emergency department (ED) complaining of exertional dyspnea, orthopnea, cough and lower extremity edema. His medical history was remarkable for hypertension and morbid obesity. In the emergency department (ED), his blood pressure was 101/62 millimeters of mercury (mmHg) with a heart rate of 88 beats/minute. His respiratory rate was 20/minute with a room air oxygen saturation of 97% (percent). His physical exam was remarkable for jugular venous distension and lower extremity edema to the mid-thigh. His brain (or B-type) natriuretic peptide (BNP) was 370. A chest X-ray showed possible early right lower lobe infiltrates. His hemoglobin level was 10.8 and his white blood cell count was 16,800. His procalcitonin level was elevated in the indeterminate range. His serum troponin level was normal. His serum creatinine level was 1.3. An electrocardiogram showed sinus rhythm with a prolonged QT interval. The patient was treated with intravenous Furosemide and antibiotics and was admitted to the hospital. Later, his respiratory rate was 18/minute with a room air oxygen saturation of 93%. On physical exam, his lungs were clear, and his edema had improved. His blood cultures were negative. Furosemide and antibiotics were continued. The patient's symptoms continued to improve. His white blood cell count was 13,200. His serum creatinine level was 1.2 . The patient was discharged.
The medical necessity for an inpatient hospital admission is at issue.

I uphold, in whole, the health plan's determination that an inpatient level of care was not medically necessary.

No. Based on the documentation provided, an inpatient level of care was not medically necessary.
This patient presented to the hospital and was admitted for management of decompensated heart failure and possible community acquired pneumonia. Regarding his heart failure, he did not have high risk features such as serum troponin elevation, marked BNP elevation, significant hyponatremia, systolic blood pressure less than 100 mmHg or an oxygen saturation less than 90%. He responded well to treatment with intravenous Furosemide. Based on his Emergency Heart Failure Mortality Risk Grade score, his 7-day mortality risk was low. In stable heart failure patients, such as this man, without high-risk features, studies have shown that observation level care is safe and effective, with similar outcomes, including readmission, repeat emergency department visits and 30 day mortality, when compared to those treated as inpatients. Thus, in this instance, an alternate level of care would have been sufficient for management of this man's heart failure; an inpatient admission was not medically necessary.
There was some suspicion that the patient might have had community acquired pneumonia. He did not have high risk features such as age 65 years or greater, mental status changes, hyponatremia, tachycardia, hypoxia, signs of sepsis or systemic inflammatory response syndrome or pleural effusion. If he did indeed have community acquired pneumonia, he was at low risk for major adverse events and it could have been managed on an outpatient basis.
The Milliman Care Guideline, Heart Failure, was provided for review. This patient did not meet any of the listed indications for inpatient admission.