Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

This male with a history of coronary artery disease (CAD), diabetes mellitus (HTN), and congestive heart failure (CHF) presented with acute shortness of breath. 

Vital signs were as follows: temperature 96, pulse 66, respiratory rate 18, blood pressure 151/93, and oxygen saturation 95%.  Exam was remarkable for wheezes and rales, with no edema.  Labs were remarkable for blood urea nitrogen (BUN) / creatinine (Cr) 63/5.5, bicarbonate (HCO3) 18, brain natriuretic peptide (BNP) 3470, and troponin .04.  The patient arterial blood gas (ABG) was 7.3/37/184/18.7.  The patient was managed with bi-level positive airway pressure (BiPAP), nitro drip x1 hour and intravenous (IV) Lasix x1.  The patient was comfortable and feeling better after treatment; his blood pressure was 135/80s.  Chest x-ray (CXR) revealed pulmonary vascular congestion.  Electrocardiogram (EKG) showed normal sinus rhythm (NSR), bifascular block, and no acute changes. 

The patient was admitted with acute heart failure secondary to uncontrolled hypertension due to medial noncompliance.  Plan of care included Lasix, home antihypertensive medication, and Nephrology consult for dialysis.  The nitroglycerin (NTG) drip was discontinued. 

Day 2, vital signs were stable. The patient's blood pressure (BP) was 162/83.  The patient felt better.  Lasix was adjusted to 40 milligrams (mg) two times a day (bid).  The patient refused dialysis.  Day 3 vital signs were stable.  An echocardiogram was performed.  On day 4, vital signs were stable.  Plan was for nuclear stress test.  The next day, the patient was discharged to home. 

No, the proposed inpatient stay was not medically necessary. 
Medically necessary services are those which are: 
- safe,  
- effective, 
- generally accepted national standard of medical practice, 
- not provided primarily for convenience of the patient or the practitioner,  
- the least intensive and/or most appropriate alternatives among diagnostic and treatment option. 

The requested inpatient admission was not medically necessary because it was not in accordance with generally accepted national standard of medical practice. 

This patient with a history of heart failure, hypertension, chronic renal failure, and medication noncompliance was admitted after presenting with onset of acute shortness of breath.  He symptomatically responded to treatment while in the emergency room (ER).  He was hemodynamically stable.  At time of admission, he did not have tachycardia, tachypnea or hypos.  His blood pressure was stable.  He did not have pulmonary or lower extremity edema.  Management included diuresis and resuming home medications.  He was not receiving continuous intravenous therapy.  He remained clinically stable throughout hospital stay.  He did not receive interventions that required an acute inpatient level of care. 

Recommendations by the American College of Cardiology and the American Heart Association for admission due to congestive heart failure (CHF) include admission for: respiratory distress (respiratory rate greater than (>) 40 breaths per minute) or pulmonary edema; hypoxia (oxygen saturation less than (<) 90%); anasarca or significant edema (plus-two [+2]); syncope or hypotension (systolic blood pressure 80 millimeters of mercury [mm Hg]); congestive heart failure of recent onset (no past history of congestive heart failure); evidence of ischemia (chest pain symptoms); inadequate social support for outpatient management; failure of outpatient management; or concomitant acute medical illness.  The member did not have these findings as noted above.  He had not failed a lesser level of care.  Inpatient hospital admission was not medically necessary.