Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestive heart failure

Treatment: Inpatient admission 

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

The patient was a male who presented to the Emergency Department (ED) complaining of shortness of breath and right leg pain. The patient's past medical history included heart failure due to non-ischemic cardiomyopathy, status post automatic implantable cardioverter defibrillator (AICD), hypertension, status post craniotomy and tracheotomy due to an automobile accident, umbilical hernia, chronic cigarette smoking and history of alcohol abuse. The patient's right leg pain was described as being 7 out of 10 in pain severity, which worsened with movement. The patient's medications included apixaban, aspirin, atorvastatin, digoxin, Lasix and lisinopril. In the ED, the patient's vital signs were: temperature of 97.7, pulse rate of 72, respiratory rate of 18, blood pressure of 114/72, and oxygen saturation of 97% on room air. On physical examination, the patient was described as being in no apparent distress; rales and rhonchi were described in his pulmonary exam. The patient also had pedal edema (3+). The patient's urine toxicology screen was positive for cocaine. The patient informed the hospital staff that he would like to leave the hospital against medical advice. The patient was given the address and phone number of outpatient clinics for follow-up care.

Acute decompensated heart failure (adHF) is the cause of approximately 1 million annual hospital admissions. In some of these, the use of a short-stay emergency department observation unit (EDOU) decreases 90-day ED revisits and 90-day re-hospitalizations and, if subsequent hospitalization is required, results in shorter stays. These investigators attempted to determine whether laboratory and clinical parameters, available at ED arrival, predict successful EDOU discharge. Factors which identify CHF patients as being at high risk include elevated BUN and creatinine, hyponatremia, ischemic changes on EKG, very elevated BNP levels, elevated troponins and low systolic blood pressure. (2)

There has been extensive prior investigation of high-risk physiologic markers in ED patients with acute heart failure. Renal dysfunction, low blood pressure, low serum sodium, and elevated levels of natriuretic peptides or troponin have all been associated with an increased risk of morbidity and mortality. When the emergency physician encounters such high-risk markers, the disposition decision is straightforward: the patient is typically admitted to the hospital for further treatment and risk stratification. (3)

In this case, the patient presented to the hospital with a complaint of shortness of breath and was found to be in congestive heart failure. The patient was known to have severe non-ischemic cardiomyopathy and had an automatic implantable cardioverter defibrillator (AICD) implanted because of a very low ejection fraction. This patient had many significant risk factors that warranted this patient's inpatient admission. These risk factors included this patient's very elevated BNP, and abnormal troponin value, elevated BUN, an AICD in place in addition to other risk factors including use of substance, which made it less likely that he would be compliant with his medications. The literature review indicates that patients who present to the Emergency Department (ED) with heart failure have a significant risk of mortality if they are not admitted and properly treated. For these reasons, considering this patient's high-risk comorbidities and clinical presentation, inpatient admission was medically necessary for this patient.

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.