Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems
Treatment: Inpatient Hospital
The insurer denied: Inpatient stay
The denial is: Upheld in whole

The patient is a male who presented to the hospital with worsening of chronic shortness of breath. The patient started to experience orthopnea, leg swelling, pleuritic chest pain, and decreased exercise tolerance. He also experienced dry cough and watery eyes for one week. At baseline, the patient is on 3 liters (L) nasal cannula at home, and despite albuterol nebulization, symptoms did not improve.

On exam, the patient appeared comfortable. He did have bilateral crackles up to the mid lung. There was distant heart sounds with no murmurs rubs or gallops. Neurologically he was intact.
Laboratory studies revealed normal hemoglobin, white count, and international normalized ratio (INR). Liver function tests (LFTs) were fairly unremarkable. He tested negative for influenza A, B, and respiratory syncytial virus.
On chest x-ray, there was pulmonary vascular congestion but no pleural effusions. The patient was admitted to the hospital and started on intravenous (IV) Lasix. An echocardiogram was ordered to evaluate the ejection fraction.
The following day, vital signs were stable. There were no abnormalities on the telemetry. The patient endorses improvement in symptoms with Lasix. On exam, he has trace lower extremity edema. The echocardiogram report shows normal ejection fraction, no regional wall motion abnormalities, no evidence of diastolic dysfunction.
Treatment of intravenous (IV) Lasix was continued. The patient's regiment of inhaled corticosteroids and bronchodilators was maintained as well.
The following day, the patient reported a desire to go home. On the telemetry review, there were some bradycardic episodes with heart rates of 49-50. The intake and output measurements showed a net negative of 250 milliliter (mL).Blood urea nitrogen (BUN) and creatinine remained stable. The medical team decided to continue with IV Lasix 20 milligrams (mg), with plans to transition to oral Lasix next day.
The next day, the patient was feeling much better, and denied any shortness of breath. The patient was discharged home with close outpatient follow-up. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld in whole.

The admitting diagnosis for this patient is documented as acute diastolic heart failure. There is no documentation that supports an acute coronary syndrome. There is no evidence of pulmonary embolism, causing the patient's pulmonary edema and lower extremity edema. There is no documentation that supports the presence of anasarca with tissue breakdown. Within 48 hours of hospitalization, the patient's symptoms had improved, there was trace pitting edema only, and the oxygen level remained at baseline. There is no documentation of unresolving tachypnea, respiratory distress, altered mental status, or worsening creatinine, that would warrant intensive monitoring. There is no documentation of hemodynamic instability or severe electrolyte abnormalities. The echocardiogram showed preserved ejection fraction, no regional wall motion abnormalities. There is also no clear evidence of diastolic dysfunction based on the report.
The acuity of the patient's condition did not warrant inpatient hospitalization. The patient could have been managed under a lower level of care status. This is in accordance with generally accepted standards of medical practice, recognized by the relevant medical community, physicians specialty society recommendations, as based on credible scientific evidence published in the peer-reviewed medical literature.