Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Cardiac/Circulatory Problems.  
Treatment:  Inpatient Hospital. 

The insurer denied inpatient hospital admission.  The denial was overturned. 

The patient is a male with a past medical history significant for nonischemic cardiomyopathy, who presented to the emergency department with complaints of shortness of breath and significant weight gain that he noted within the two weeks before his presentation.  The patient denied chest pain, fever, chills.  In the emergency department, the patient underwent a chest x-ray that was positive for pulmonary vascular congestion.  He received treatment with intravenous Lasix.

When he was seen by the admitting physician his temperature was 97.2F, blood pressure was 145/87, respiratory rate was 30 breaths per minute, and oxygen saturation was 95%.  The head, eyes, ears, neck, throat (HEENT) exam was within normal limits. The neck was supple without lymphadenopathy, masses, jugular vein distention (JVD), or carotid bruits.  The patient had labored breathing and bilateral crackles on the pulmonary exam.  The patient had a regular rate and rhythm, without murmurs, rubs, or gallops.  The abdomen was soft and nontender.  The rest of the physical exam was unremarkable, except for the presence of 2+ bilateral lower extremity edema.

His laboratory evaluation revealed that his white blood cell count was 5.1, hemoglobin was 10.1, hematocrit was 31.5, and platelets were 153.  His sodium was 142, potassium was 4.2, chloride was 103, bicarbonate was 26, blood urea nitrogen (BUN) was 35, creatinine was 1.8, and glucose was 128.

The patient was admitted to the hospital with a diagnosis of acute congestive heart failure.  The patient was started on intravenous Lasix.  Other clinical problems included drug abuse, depression, and anxiety.  In the hospital, the patient was seen by a cardiologist, who also recommended treatment with intravenous loop diuretics.  

During the hospital stay the patient's clinical condition improved, including improvement in the respiratory symptoms and lower extremity edema.  The patient's kidney function was monitored closely.

Since the patient's clinical condition improved, he was discharged home.

The health plan's determination of medical necessity is overturned in whole.

The requested service/treatment of inpatient hospital admission was medically necessary for this patient.

The duration and complexity of care justified admission at the acute inpatient level of care.  This patient required administration of intravenous diuretics for the treatment of acute exacerbation of heart failure.  The review of the medical records clearly demonstrated that the patient benefited from the administration of intravenous diuretics performed during the hospital stay.  Treatment with intravenous diuretics is more effective than oral diuretics for the treatment of acute exacerbation of congestive heart failure.  However, this treatment is associated with close monitoring, especially in cases of kidney insufficiency, since the dose of diuretics and the frequency of administration should be adjusted accordingly.  The most efficient way to provide care is admission to the hospital.  The close monitoring was essential in this clinical case, considering abnormalities in kidney function.

Taking into consideration these facts, the inpatient hospital admission was completely justified and medically necessary.