Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath/dyspnea
Treatment: Inpatient Hospital Services
The insurer denied the inpatient hospital services.
The denial is upheld.

The patient is a female, who initially presented to the emergency department with concerns of shortness of breath for one week. Pertinent history included chronic kidney disease stage 5, diastolic congestive heart failure, atrial fibrillation, and diabetes mellitus. Initial vital signs found the patient to be afebrile, hemodynamically stable, and without hypoxia. Initial examination documented the patient as alert, oriented, and with pedal edema. Initial laboratory testing revealed a sodium of 142, a potassium of 4.4, a blood urea nitrogen (BUN) of 53, a creatinine of 3.1, a glucose of 131, a brain (or B-type) natriuretic peptide (BNP) of 1371, a Troponin I of 0.04, a thyroid stimulating hormone (TSH) of 0.03, a white blood cell (WBC) count of 5.6, and a hematocrit of 24. An electrocardiogram (EKG) was unremarkable. A chest radiograph revealed a mildly prominent heart with pulmonary vascular congestion. The patient was placed in the hospital thereafter with an impression of shortness of breath due to either acute diastolic heart failure versus worsening renal function. The treatment plan included a dose of Furosemide, serial cardiac enzymes, and an echocardiogram. The following day, the echocardiogram revealed a preserved left ventricular ejection fraction (LVEF) with valvular heart disease. The patient was deemed medically stable and was discharged on her home diuretic dose.

At issue is the medical necessity for the inpatient hospital services.

The health plan's determination of medical necessity is upheld, in whole.

Based on the clinical documentation provided, evidence based literature, and standards of care, an acute inpatient level of care was not indicated as medically necessary for the entire admission. Evaluation and management could have been performed at an alternate level of care.

Yancy, et al. note there is no widely accepted nomenclature for heart failure (HF) syndromes requiring hospitalization. Patients are described as having "acute HF," "acute HF syndromes," or "acute(ly) decompensated HF"; while the third has gained greatest acceptance, it too has limitations, for it does not make the important distinction between those with a de novo presentation of HF from those with worsening of previously chronic stable HF. Hospitalized patients with HF can be classified into important subgroups. These include patients with acute coronary ischemia, accelerated hypertension and acutely decompensated HF, shock, and acutely worsening right HF. Patients who develop HF decompensation after surgical procedures also bear mention. Each of these various categories of HF has specific etiologic factors leading to decompensation, presentation, management, and outcomes. [1] In this particular situation, the patient did not have acute coronary ischemia, accelerated hypertension, or shock.

The Heart Failure Society of America (HFSA) guidelines suggest that hospital admission is recommended for patients with acute decompensated heart failure (ADHF) with the evidence of severely decompensated HF including hypotension, worsening renal function, altered mentation, hemodynamically significant arrhythmia including new onset atrial fibrillation with rapid ventricular response, or acute coronary syndromes. [2] In this particular situation, the patient did not meet any of these criteria.

The HFSA goes on to suggest that hospitalization should be considered for patients with acute decompensated HF with worsened congestion (even if without dyspnea at rest), signs and symptoms of pulmonary or systemic congestion, even in the absence of weight gain, or previously undiagnosed HF with signs and symptoms of systemic or pulmonary congestion. [2] In this particular situation, the patient did meet this criteria that would advise the consideration of hospitalization.

The patient had a history of chronic kidney disease stage 5 and chronic diastolic congestive HF. She presented with shortness of breath of one week duration. Initial evaluation found the patient to be hemodynamically stable and without hypoxia. An echocardiogram revealed a LVEF of 60% (percent) with valvular heart disease. The treatment plan included a dose of diuretic therapy and withholding of some home medications. Following a night of observation, the patient was deemed medically stable and was discharged. No other issues or complications were documented.

Moreover, clinical indications for admission to inpatient care were not met. The patient did not have hemodynamic instability, cardiac arrhythmias of immediate concern, sever electrolyte abnormalities requiring inpatient care, acute cardiac ischemia, pulmonary edema that is very sever or persistent (e.g. ["for example"] new oxygen requirement from baseline), persistent tachypnea, altered mental status, progressively (ongoing) rising creatinine with reduction of more than 25% in estimated glomerular filtration rate (GFR), persistent dyspnea (above baseline) or any other associated condition requiring inpatient level monitoring. [3]

The health plan's determination of medical necessity is upheld, in whole.