Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute exacerbation of chronic systolic heart failure 

Treatment: Inpatient admission 

The insurer is denied coverage for inpatient admission.  
The denial is overturned. 

The patient was a male who came to the Emergency Department (ED) with complaint of progressive shortness of breath. The patient reports that this symptom had been going on for then the past several days, and had then worsened to shortness of breath even at rest. The patient reported reduced functional capacity; only able to walk 10-15 steps without becoming short of breath. The patient also reported to having paroxysmal nocturnal dyspnea (PND), orthopnea and leg swelling. The patient had medications for treating heart failure but reported that he had not been taking them regularly for the past few days. The patient had a cough which was productive of thick white sputum, but no fever chills and hemoptysis. The patient also had chronic pain in the left upper chest and left shoulder for almost surgery. The patient denied new chest pain or worsening of his previous chest pain. The patient reported smoking marijuana daily and using cocaine and heroin frequently. The patient's last use of cocaine and heroin was one week ago. The patient took oxycodone and Percocet to treat his chronic pain. 

The patient's past medical history also included congestive heart failure (CHF) with low ejection fraction, status post implantable cardioverter-defibrillator (ICD) done and CABG done. The patient had an angiogram done which showed that he had tripled vessel disease. The patient also had hypertension dyslipidemia, chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD), gastroesophageal reflux disease (GERD) and gout. The patient also had a history of bipolar disorder. Additional past surgical history included an umbilical hernia repair and fracture surgery on his right foot. His review of systems was positive for fatigue, headache, cough, chest pain at rest, abdominal pain and discomfort due to constipation, urinary hesitancy and diffuse joint pain. The patient's initial vital signs included temperature 97.9, pulse 96, respirations 20, blood pressure 110/77 and oxygen saturation 95% on room air. The patient's vital signs recorded the next day included temperature 97.8, pulse 135, respirations 20, blood pressure 105/78 and oxygen saturation 96% on room air. On physical exam, the patient was described as being in mild respiratory distress and noted headache and whole-body pain; the patient had jugular venous distension (JVD) present to the mandible; the patient's respirations were described as shallow and the use of his accessory muscles was mild. 

The patient was admitted to the Telemetry Unit because of his complaint of chest pain in addition to atrial fibrillation with rapid ventricular response and acute exacerbation of chronic systolic heart failure possibly due to medication noncompliance. The patient was started on metoprolol and Eliquis; amiodarone was also given. The patient's heart failure was managed with intravenous (IV) Lasix. The patient was also started on Entresto, spironolactone and metoprolol. The patient's laboratory results included glucose 122, BNP 2997, BUN 16, creatinine 1.43, hematocrit 35.7, sodium 141, magnesium 2.0, initial troponin 0.04, white blood cell (WBC) count 5.6; his urine screen for drugs was positive for cannabinoids. The patient was discharged home with instructions to continue taking his Eliquis, in addition to his other medications, and to follow up as an outpatient with his primary care physician and his cardiologist.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for the inpatient admission is substantiated. The insurer's denial should be reversed.