Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestive heart failure (CHF)

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This patient presented to the hospital with complaints of chest pain, shortness of breath, lower extremity swelling and abdominal distension. Relevant past medical history included hypertension, heart failure with preserved left ventricular ejection fraction (LVEF), morbid obesity, peripheral vascular disease, chronic obstructive pulmonary disease (COPD) on home oxygen, obstructive sleep apnea and diabetes mellitus. On arrival, vital signs were stable with blood pressure (BP) 135/54 and pulse 87 beats per minute. Physical exam revealed pedal edema and tachypnea with a respiratory rate of 24 breaths per minute. 12 lead electrocardiogram revealed normal sinus rhythm with low voltage and no ST or T wave abnormalities. Serum blood testing demonstrated an arterial partial pressure of carbon dioxide (pCO2) level of 78, elevated brain natriuretic peptide (BNP) level (748), elevated blood urea nitrogen (BUN) and Creatinine (45 and 1.2 respectively) and an elevated potassium level of 5.3. No elevation in serum troponin was noted. The patient was treated with diuretics and bilevel positive airway pressure (BiPAP) therapy and admitted to telemetry for acute respiratory failure due to heart failure with preserved LVEF. She was subsequently found to be lethargic with worsening hypercapnia (pCO2- 106) and was transferred to the intermediate care unit (IMCU) and aggressive BiPAP therapy. Echocardiogram revealed an LVEF of 60%, moderate pulmonary hypertension and moderate aortic stenosis. Computerized tomography angiography (CTA) was negative for pulmonary embolism, but bilateral interstitial infiltrates were noted, and the patient was treated for pneumonia with intravenous (IV) antibiotic therapy. Ultimately the patient condition improved, and she was discharged to a subacute rehabilitation facility.

This patient presented with decompensated CHF. The patient was noted to be markedly hypercapnic on admission. Initial treatment with diuretics and oxygen failed to result in any improvement. The patient ultimately became lethargic with worsening hypercapnia requiring BiPAP therapy and IMCU care. In addition, this patient was found to have bilateral infiltrated on computed tomography (CT) chest and required treatment for pneumonia. This patient could not have been managed at an alternate level of care and required inpatient treatment and follow up. There have been several studies including a meta-analysis of more than 50,000 patients demonstrating poor outcomes for patients that are discharged from the emergency department after presenting with CHF. These findings were true in both systolic and diastolic CHF. (1,2) In conclusion, it was appropriate to manage this patient at an inpatient level of care. Full hospital admission was medically necessary.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for inpatient admission is overturned. Medical Necessity is substantiated.