Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest tightness and shortness of breath
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

The patient is an adult male. He was hospitalized for prolonged. 
chest tightness and shortness of breath, in the setting of recent successful PCI (percutaneous coronary intervention). His past medical history was pertinent for known CAD (coronary artery disease) with PCI (percutaneous coronary intervention) to the mid and distal LAD (left anterior descending), insulin dependent diabetes complicated by diabetic nephropathy, neuropathy and retinopathy, hypertension and hyperlipidemia.
The patient's vitals were stable. His O2 (oxygen) saturation was 98% on room air. There were pulmonary crackles and trace bilateral leg edema. Bedside echocardiogram showed LVEF (left ventricle ejection fraction) between 30-50%(percent) and no pericardial effusion. Chest x-ray showed cardiomegaly. Troponin was elevated to 2.9 and felt to be trending down and secondary to recent PCI (percutaneous coronary intervention) coronary revascularization, CPK (creatine phosphokinase) was normal and so low suspicion for reinfarction. Pro BNP (brain natriuretic peptide) was elevated to 545. The clinical impression was no CHF (congestive heart failure), and treatment included IV (intravenous) Lasix with a good response. The request for coverage for acute inpatient hospitalization was denied by the health plan as not medically necessary. The decision is being appealed.

The Inpatient Hospital Admission was not medically necessary.

Based on the peer-reviewed medical literature and this reviewer's expert medical opinion, the documentation submitted for review do not establish the requested Acute Inpatient Hospital Stay was medically necessary for this patient. According to the MCG (Milliman Care Guidelines) Guidelines 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, cardiac arrhythmias of immediate concern, myocardial ischemia or myocardial infarction, positive troponin not explained by CKD (chronic kidney disease) and CHF (congestive heart failure), hypertension requiring inpatient hospitalization, CVA (cerebrovascular accident), pulmonary embolism, 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. In this particular case, there was no clinical decline or inadequate response to treatment which required continuation of the hospital stay past the observation period. The care the patient received for new, uncomplicated LV (left ventricle) systolic HF (heart failure) is routinely provided safely and effectively at a lower level of care. Therefore, the inpatient admission was not medically necessary.