Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Decompensated heart failure
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

The patient is an adult male with history of congestive heart failure (CHF), hypertension and peripheral arterial disease, status post left femoral popliteal bypass and on anticoagulant therapy. The patient presented to the emergency department (ED) with complaints of shortness of breath and cough. The patient denied any chest pain. The patient reported that he had been non-compliant with his diet and had also missed doses of his diuretics and other maintenance meds for the past few days.

Vital signs at presentation were temperature 98.2, blood pressure 154/107, heart rate 108, respiratory rate 20 and oxygen saturations 98 %. The patient was in no acute distress, had clear breath sounds, cardiovascular system (CVS) was normal (S1 S2) with no pedal edema noted. He was alert and oriented X 3 with a non-focal neuro exam.

Labs showed a normal white blood cell count, brain natriuretic peptide (BNP) 505, troponin 0.05, electrolytes within normal limits and blood urea nitrogen (BUN)/ Creatinine 23/1.42.

Electrocardiogram (EKG) showed left atrial and left ventricular hypertrophy. There were no ischemic changes. Chest x-rays (CXR) revealed no acute infiltrates or effusion.

The patient was diagnosed to have decompensated heart failure. He was given intravenous (IV) Lasix in the ED. His BUN/Creatinine trended higher on the day prior to discharge with value of 27/1.71 and on day of discharge with value of 30/1.64. His Lasix was held. Once the patient started showing a decline in creatinine, the patient was restarted on oral (PO) Lasix.

An echocardiogram revealed an ejection fraction of 25%. The patient was seen by Cardiology who agreed with continuing diuretics.

The patient remained stable after admission He was discharged home on PO medications. 

The patient did not need acute inpatient hospitalization. He was afebrile and hemodynamically stable, his CHF was mild, there was no jugular vein distention, his lungs were clear and there was no pedal edema. The patient's BNP was mildly elevated, CXR showed no pulmonary congestion or pleural effusion, and he was able to speak in full sentences. The patient did not have a myocardial infarction. 

An inpatient admission was not medically necessary for this patient. The patient could have been placed in observation status which could be for up to 48 hours. During that time, diagnostic testing and treatment could have been initiated. His symptoms were related to his dietary and medical noncompliance. The patient could have been treated with gentle diuresis while in observation if needed. He did not have any significant volume overload and in fact became prerenal just after 1 dose of IV Lasix. The patient remained stable after admission. He was stable for discharge on PO meds after a brief period in observation. The patient was stable for follow up in the outpatient setting.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for inpatient admission is upheld. Medical Necessity is not substantiated.