Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Congestive Heart Failure
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld.
 
The patient is an adult male with a history of congestive heart failure (CHF), chronic kidney disease (CKD) hypertension and atrial flutter on Eliquis, who presented to the emergency department (ED) with complaints of shortness of breath and bilateral (B/L) Lower extremity (LE) edema.

The patient reported compliance with medications but endorsed increased fluid intake. He had been recommended for automatic implantable cardioverter defibrillator (AICD) in the past but had refused. The patient was recently discharged from hospital after an admission for the same complaints.

Vital signs at presentation were: Temperature 97.5 degrees Fahrenheit, Heart Rate 116, Blood Pressure 115/79, Respiratory Rate 19. Oxygen saturation was 95% on room air. The History and Physical noted that the patient was in no apparent distress, no Jugular Vein Distention (JVD), Normal heart sounds with tachycardia. The lungs were clear on auscultation. On examination the abdomen was soft and non-tender, edema of lower extremities was present. The patient was alert and oriented to person, place and time.

White blood cell (WBC) count was 7.3, Hemoglobin (Hgb) 12, Electrolytes within normal limits (WNL), Blood Urea Nitrogen (BUN)/Creatinine (Cr) 35/1.6 with baseline  Cr 1.5.Troponin was Negative and B-type Natriuretic Peptide (BNP) > 4700. Electrocardiogram (EKG) showed Atrial  Fibrillation with rapid ventricular response (RVR). Bed Side transthoracic echocardiogram (TTE) showed ejection fraction (EF) of <30 %.

Chest X-ray showed Cardiomegaly. No effusion or infiltrates were reported.

The patient was given intravenous (IV) Lasix in the emergency department (ED) following which he diuresed 2.5 liters of urine. He was continued on oral home meds. The patient remained stable after admission and was seen by Cardiology. Troponins remained negative and Myocardial Infarction (MI) was ruled out. Patient was continued on IV (intravenous) Lasix once a day and cardiac medications. AICD (automatic implantable cardioverter defibrillator) insertion was recommended as an outpatient procedure.

The patient was afebrile and hemodynamically stable. Oxygen saturation was 97% on room air and he was in no apparent distress. Lungs were clear. Acute Coronary Syndrome had been ruled out and the patient was tolerating oral food and fluids. 
White blood cell (WBC) count was 4.6, Electrolytes within normal limits (WNL), Blood Urea Nitrogen (BUN)/Creatinine (Cr) 34/1.6.

The patient remained stable and signed out against medical advice (AMA).

This patient did not require acute inpatient hospitalization. He had known congestive heart failure (CHF) and had some decompensation from increased fluid intake which responded well to diuretics. He had clear lung fields, no Jugular Vein Distention (JVD) and was not hypoxic. He remained hemodynamically stable.

This patient could have been placed in Observation status while diagnostic testing and treatment were continued. He was stable to be discharged home on diuretics and oral medications with close follow up in the outpatient setting.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is not substantiated.