Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of Breath
Treatment: Inpatient Emergency Admission
The insurer denied the inpatient emergency admission.
The health plan's determination is upheld.

The patient is a male who initially presented to the emergency department with concerns of shortness of breath. His pertinent medical history included non-ischemic cardiomyopathy (left ventricular ejection fraction (LVEF) 20 percent (%)), congestive heart failure, paroxysmal atrial fibrillation, thrombocytopenia chronic kidney disease stage 3, diabetes mellitus, and hypertension. His initial vital signs revealed a temperature of 98.7, a heart rate (HR) of 88, a blood pressure (BP) of 144/103, a respiratory rate (RR) of 20 and his peripheral capillary oxygen saturation (SpO2) was 97% on room air. The initial examination documented tachypnea and decreased breath sounds.

The initial laboratory testing revealed a white blood cell count (WBC) of 4.7, a hemoglobin (Hgb) of 16.3, his platelets (Plt) were 185, his sodium was 142, his potassium was 3.7 and his blood urea nitrogen (BUN) was 16, creatinine 1.32. His glucose was 138, his magnesium was 1.5, his total bilirubin was 2.6. His international normalized ratio was 1.5, his creatine kinase (CK) was 270, his Troponin I was 0.07 (baseline) and his brain (or B-type) natriuretic peptide (BNP) was 288. 

The chest radiograph revealed clear lungs. The computed tomography angiography (CTA) of the chest did not reveal a pulmonary embolism, pneumonia, or pulmonary edema. Lasix 40 milligrams (mg) intravenous (IV) was provided with clinical improvement. The plan was for a hospital admission for mild exacerbation of congestive heart failure. Cardiology was consulted and had an impression of acute on chronic systolic congestive heart failure, left ventricular (LV) thrombus, and recently found atrial fibrillation on device interrogation. Recommendations were to continue diuretics, resume home cardiac medications, and initiate anticoagulation.

The patient was afebrile and hemodynamically stable without hypoxia. The admitting physician had an impression of acute on chronic congestive heart failure, LV thrombus, and atrial fibrillation. The treatment plan was to transition the patient to oral diuretics and to initiate therapeutic Lovenox as well as Warfarin. The patient's diuretics were changed to a daily oral regimen. There were no other significant changes in the treatment plan. The treatment plan noted to follow-up at an anticoagulant (INR) clinic post-discharge. 

Yancy et al. notes there is no widely accepted nomenclature for heart failure (HF) syndromes requiring hospitalization. Patients are described as having "acute HF," "acute HF syndromes," or "acute(ly) decompensated HF"; while the third has gained the greatest acceptance, it too has limitations, for it does not make the important distinction between those with a de novo presentation of HF from those with worsening of previously chronic stable HF. Hospitalized patients with HF can be classified into important subgroups. These include patients with acute coronary ischemia, accelerated hypertension and acutely decompensated HF, shock, and acutely worsening right HF. Patients who develop HF decompensation after surgical procedures also bear mention. Each of these various categories of HF has specific etiologic factors leading to decompensation, presentation, management, and outcomes.[1]

The patient did not have hemodynamic instability, severe electrolyte abnormalities requiring inpatient care, cardiac arrhythmias of immediate concern, acute myocardial ischemia causing heart failure and pulmonary edema that is very severe. The patient did not have pulmonary edema that is persistent, tachypnea that persists, dyspnea above baseline that persists, an altered mental status, or increased creatinine with reduction of more than 50% in estimated glomerular filtration rate from baseline.[3]