Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart Failure
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient presented to the emergency department complaining of lower extremity edema and exertional dyspnea. His medical history was remarkable for nonischemic cardiomyopathy with a left ventricular ejection fraction (LVEF) of 45%, congestive heart failure, hypertension, hyperlipidemia, stroke and systemic lupus erythematosus. He reported noncompliance with his prescribed medications for one month. His blood pressure was 156/107 millimeters of mercury (mmHg) with a heart rate of 99 beats/minute. His respiratory rate was 18 breaths/minute with a room air oxygen saturation of 99%. His physical exam was remarkable for obesity and "massive" lower extremity edema. A chest x-ray showed a small right pleural effusion. His brain (or B-type) natriuretic peptide (BNP) level was 1282 picograms per milliliter (pg/ml). The troponin level was normal. An electrocardiogram showed no acute changes. His serum albumin level was 2.1 grams per deciliter (g/dL). The patient was treated with intravenous furosemide and admitted to the hospital. Twice daily intravenous furosemide was prescribed. An echocardiogram showed a left ventricular ejection fraction (LVEF) of 35%, which was decreased compared to prior studies. The patient's edema was somewhat improved; there was pitting edema to the knees bilaterally. There was no change in his edema which was described as 3 plus (+) bilaterally. The patient's serum sodium level fell to 133 millimoles per liter (mMol/L). Metolazone was added to the furosemide. The patient had improvement in his edema; it was described as 2+ bilaterally. His serum sodium level improved. The intravenous furosemide was discontinued and oral furosemide was started. There was further improvement and the patient was discharged. At issue is the medical necessity of an inpatient level of care.

Based on the documentation provided, an inpatient level of care was medically necessary. This patient presented with acute decompensated heart failure (ADHF). His BNP level was markedly elevated at 1282 pg/ml. In the Acute Decompensated Heart Failure National Registry (ADHERE) registry, admission BNP values in the highest quartile (BNP greater than or equal to (>=) 1730 pg/mL) in patients with acute decompensated heart failure (ADHF) were associated with a 2.23-fold increase in in-hospital mortality compared with BNP levels in the lowest quartile (less than [<] 430 pg/mL), even after adjustment for potential confounders and regardless of ejection fraction. The patient's edema persisted despite treatment in the emergency department and several days of in-hospital treatment with twice daily intravenous furosemide. His serum sodium fell to 133 mMol/L, which was a poor prognostic sign. Hyponatremia in the setting of ADHF is associated with increased in-hospital and post-discharge mortality, prolonged hospital length of stay, and frequent rehospitalization. Given this patient's poor prognostic features and lack of response to initial therapy, he required careful and continuous monitoring, with the ability to intervene emergently, if needed. This warranted an inpatient admission.