Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute congestive heart failure
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

This male patient was hospitalized for an acute congestive heart failure (CHF) exacerbation. His past medical history was significant for known, advanced non-ischemic cardiomyopathy with last left ventricular ejection fraction (LVEF) of ten percent, implantable cardioverter defibrillator (ICD) status, noncompliance, alcohol and polysubstance abuse and cirrhotic liver disease. The patient presented to the emergency department for evaluation of increasing shortness of breath, bilateral leg swelling, fatigue, nausea and worsening anxiety.  

The patient's examination revealed that he was uncomfortable with abdominal distension, reduced breath sounds bilaterally and leg edema. He admitted to alcohol abuse and noncompliance taking his medications. His alcohol level was markedly elevated at 312.7. His Troponin was 48.8 and pro b-type natriuretic peptide (proBNP) was 3577.4. The patient's electrocardiogram (EKG) revealed sinus tachycardia, rate 115, and precordial ST segment [the flat, isoelectric section of the ECG between the end of the S wave (the J point) and the beginning of the T wave] depression. Chest film revealed cardiomegaly with central venous congestion. Treatment included intravenous Lasix and the patient signed out against medical advice (AMA). 

This is an appeal of the denied claim for the requested acute inpatient hospital stay for this patient.

No, the proposed treatment was not medically necessary.

Based on the peer reviewed medical literature, the documentation submitted for review does not establish that the requested acute inpatient hospital stay was medically necessary for this patient. According to the Milliman Care Guidelines (MCG) titled: Heart Failure (ORG: M-190), inpatient admission was not medically necessary, because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay per the guideline. Criteria for inpatient stay are not met, including documentation of hemodynamic instability, respiratory distress, change in mental status, severe heart failure, pulmonary edema, cardiac arrhythmias of immediate concern, myocardial ischemia or myocardial infarction, positive troponin not explained by chronic kidney disease (CKD) and congestive heart failure (CHF), hypertension requiring inpatient hospitalization, cerebral vascular accident (CVA), pulmonary embolism (PE), aortic dissection, pneumonia, severe electrolyte abnormalities or any other medical condition or other medical instability or acute care needs for which emergency and observation care have failed or are not considered appropriate and that would require acute inpatient management. The care the patient received for mildly decompensated, chronic left ventricular (LV) systolic heart failure (HF) due to medical noncompliance and ongoing alcohol abuse not complicated by acute alcohol withdrawal/delirium tremens (DTs) is routinely provided safely and effectively at a lower level of care. Therefore, the proposed treatment is not medically necessary, based on the submitted information and the current published medical guidelines.

Yes, the health plan acted reasonably, with sound medical judgment, and in the best interest of the patient.