Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Congestive heart failure

Treatment: Acute inpatient stay

The insurer is denied coverage for acute inpatient stay. 
The denial is upheld. 

The patient was then a male who presented to the Emergency Department (ED) with a complaint of shortness of breath that started the day prior. The patient was on hemodialysis and had his regularly scheduled session and then left for a 4.5 hour drive out. The patient reported starting to feel short of breath and noticed that his exercise tolerance had decreased to two blocks. The patient reported that he has had previous episodes that were similar and at those times he came to the ED to get hemodialysis. The patient's past medical history included lupus and lupus anticoagulant. The patient had a mitral valve replacement and was currently on Coumadin. The patient had congestive heart failure (CHF) with an ejection fraction of 50%. The patient was admitted for hemodialysis. 

The patient's home medications include Coumadin, hydralazine, Coreg, Nifedipine, Lasix, Imdur and losartan. The patient denied cigarette smoking, and use of alcohol or any recreational drugs. The patient's family history revealed that his father had hypertension. The patient's electrocardiogram (EKG) showed sinus tachycardia at 101 bpm; there was evidence of left ventricular hypertrophy and possible left atrial enlargement. The patient's chest x-ray revealed a right-sided internal jugular catheter and surgical changes from mitral valve surgery; the cardiac silhouette was enlarged and unchanged; there was no pneumothorax and no focal consolidation; there was no pleural effusion; there were increased pulmonary vascular markings which were unchanged. A note written on states that the patient's blood pressure (BP) at 4 AM was 182/97 and pulse was 102; the patient was asymptomatic at the time. The patient denied any pain or discomfort and was being discharged home. At the time of discharge, the patient was advised to continue his outpatient medications and to follow up with his physicians and dialysis as an outpatient.

Emergency-Department (ED)-based observation-unit treatment has been shown to reduce inpatient admissions, hospital bed-hours, and costs without adversely affecting outcomes for several conditions. A sequential group design study compared risk-matched, acute decompensated heart failure patients admitted directly to the inpatient setting with those admitted to an ED observation unit for up to 23 hours before ED disposition. Outcomes were 30-day readmissions or repeat ED visits for heart failure or 30-day mortality. Estimates of bed-hours and charges between the groups were compared. 

This patient presented to the hospital complaining of shortness of breath. The patient had end-stage renal disease and was on hemodialysis and had episodes of shortness of breath previously, which have been promptly treated with a hemodialysis session. with supporting documentation of medical necessity should take precedence. In this case, this patient met the clinical criteria for admission to an observation unit. The acute level of care admission was not medically necessary for this patient.

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

The carrier's denial of coverage for the acute inpatient stay should be upheld. The medical necessity is not substantiated.