Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Congestive Heart Failure.
Treatment: Inpatient admission.

The insurer denied the inpatient admission. The denial was upheld. 

This is a male patient with a medical history of coronary artery disease, congestive heart failure, status post pacemaker placement, hypertension, diabetes, gout, and a gunshot wound to the abdomen. The patient was initially treated as an inpatient in the detoxification due to alcohol and cocaine dependence. He was monitored with telemetry for management for his congestive heart failure (CHF). The patient was complaining of mild shortness of breath and increasing pedal edema. His presenting vital signs were:  temperature of 97.9F, pulse of 70, respiratory rate of 18, blood pressure of 103/70, and a pulse oximetry revealed an oxygenation level of 99%. Laboratory work up was performed that revealed a white blood cell count of 3.3, a hematocrit of 31.2, a sodium of 137, a potassium of 4.7, a blood urea nitrogen of 15.8, a creatinine of 0.77, a glucose of 109, and a magnesium of 1.2. His initial troponin was within normal limits. A computed tomography (CT) was performed that showed a moderate sized right pleural effusion, trace left pleural effusion, cardiomegaly and moderate pericardial effusion. An abdominal ultrasound was done that showed borderline hepatic enlargement, gall bladder with mild wall thickening, gallstones, upper quadrant ascites and chronic medical renal disease. An echocardiogram showed a left ventricular ejection fraction (LVEF) of 35 and grade 3 diastolic dysfunction. All chambers were dilated and there was a small pericardial effusion. An electrocardiogram (EKG) was done that showed an underlying rhythm of atrial flutter with one-to-one capture of a ventricular pacemaker. Cardiology was consulted. The patient was treated with intravenous (IV) Lasix in addition to maintaining a fluid restriction and was continued on his home medications.  The patient was medically stable and discharged with outpatient follow-up with cardiology. 

Acute decompensated heart failure (adHF) is the cause of approximately 1 million annual hospital admissions. In some of these, the use of a short-stay emergency department observation unit (EDOU) decreases 90-day ED revisits and 90-day rehospitalizations and, if subsequent hospitalization is required, results in shorter stays. These investigators attempted to determine whether laboratory and clinical parameters, available at ED arrival, predict successful EDOU discharge. This was a 19-month retrospective analysis of adHF EDOU admissions. Details of medical history, clinical course, patient management, laboratory data, and disposition destination were gathered through review of electronic medical records. Recorded laboratory data included measurements of sodium, creatinine, blood urea nitrogen (BUN), hemoglobin, b-type natriuretic peptide, and initial ED systolic blood pressure. Data were analyzed for ability to predict the requirement of hospital admission after EDOU management. There were 385 patients enrolled. The mean (+/- standard deviation) age was 69.7 (+/- 13.6) years, and 50.1% were female. On ED admission chest radiograph, 69.0% had evidence of pulmonary edema. Elevations in creatinine and BUN levels had statistically significant associations with admission; however, on multivariable analysis, only a BUN value >30 mg/dL significantly predicted EDOU management failure, and subsequent inpatient admission. These results demonstrate that a BUN level >30 mg/dL is associated with an increased likelihood of admission in patients with adHF. This provides the emergency physician with a practical prognostic tool for disposition planning in congestive heart failure patients. (1) 

The insurer acted reasonably, with sound medical judgement, and in the patient's best interest. 

Based on the above, the medical necessity for the acute inpatient stay is not substantiated. The insurer's denial is upheld.