Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lower extremity swelling and pain, abdominal
distension
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

This is a male with a history of hypertension (HTN), type II diabetes mellitus (DM) and asthma who presented with a complaint of progressive lower extremity (LE) swelling and pain and abdominal distension.  

The patient was admitted with same complaints and was diuresed.  Vital signs included: temperature 98, pulse 87, respiratory rate 16, blood pressure 103/63, and oxygen saturation 99%. Exam showed slight expiratory wheeze.  The patient had four-plus (4+) lower extremity (LE) edema, non-healing right lower extremity (LE) wounds and bilateral tenderness to palpation.   Labs included white blood cell (WBC) count 8.77, hemoglobin/hematocrit (H/H) 12/39., platelets (Plt) 182, sodium (Na) 141, potassium (K) 4.8, carbon dioxide (CO2) 29, blood urea nitrogen (BUN) / creatinine (Cr) 16/1.31, and D-dimer 150.  The patient's chest x-ray (CXR) was within normal limits (WNL).  Lower extremity Dopplers revealed no deep vein thrombosis (DVT).  

The patient was given intravenous (IV) Lasix and was admitted with hypoxemia and acute on chronic congestive heart failure (CHF).  Plan of care was for supplemental oxygen, abdominal ultrasound (US) and Lasix.  Day 1, vital signs were stable (VSS).  Oxygen saturation (O2 sat) was 98% on two liters (2L).  Oxygen was not tested on room air (RA).  Chest computed tomography angiogram was negative for pulmonary embolism (PE).  Electrocardiogram (EKG) was of poor quality.  Troponins were negative. There was one-plus (1+) lower extremity (LE) edema.   The patient was on intravenous (IV) Lasix twice daily (BID).  Day 2, vital signs were stable (VSS).  The patient's pain was improving with diuresis. The patient has an episode of non-sustained ventricular (V) tachycardia. Oxygen saturation (O2 sat) was 90-92% on room air.  The patient has two-plus (2+) edema.  Plan was for discharge tomorrow. Day 3, the patient was cleared for discharge.

No, the proposed treatment was not medically necessary.

Medically necessary services are those which are: safe, effective, generally accepted national standard of medical practice, not provided primarily for convenience of the patient or the practitioner, and the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The requested inpatient admission was not medically necessary because it was not in accordance with generally accepted national standard of medical practice.

Recommendations by the American College of Cardiology and the American Heart Association for admission due to congestive heart failure (CHF) include admission for: respiratory distress (respiratory rate greater than [>] 40 breaths per minute) or pulmonary edema; hypoxia (oxygen saturation less than [<] 90%); anasarca or significant edema (+2); syncope or hypotension (systolic blood pressure 80 milligrams of mercury [mmHg]); congestive heart failure of recent onset (no past history of congestive heart failure); evidence of ischemia (chest pain symptoms); inadequate social support for outpatient management; failure of outpatient management; or concomitant acute medical illness.  

This patient with a recent admission for heart failure was admitted with fluid overload.  The patient was hemodynamically stable.  He did not have respiratory rate (RR) greater than (>) 40 or documented hypoxia. There was no evidence of ischemia on electrocardiogram (EKG).  It is noted that the patient had significant edema with four-plus (4+) lower extremity (LE) edema.  He rapidly responded to diuresis with lower extremity (LE) edema one-plus (1+).  He remained hemodynamically stable throughout hospital stay with normal oxygenation.  Due to the significant edema at presentation due to medical noncompliance, an observation level of care was appropriate for diuresis and to resume diuretics.  Based on the patent's rapid response to diuresis, hemodynamic stability and normal oxygenation, an inpatient leave of care was not medically necessary.