Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestive Heart Failure.

Treatment: Inpatient Hospital Admission.

The insurer denied coverage for inpatient hospital admission.

The denial is overturned. 

This patient is a female with a history of ischemic heart disease status post coronary artery bypass grafting (CABG), diabetes mellitus (DM), hypertension (HTN) and pulmonary embolism (PE).  The patient presented to the Emergency Department (ED) complaining of lethargy and lightheadedness following a fall.  The patient was noted to have hypotension in her doctor's office and was sent to the ED where she was treated with intravenous (IV) fluids. The patient had recently been treated and released for similar symptoms at a nearby ED.   Following fluid bolus, the patient's vital signs were stable and physical exam revealed bilateral pedal edema.  The patient's laboratory tests revealed acute renal insufficiency [blood urea nitrogen (BUN) of 34 and creatinine (CR) of 1.7], hyperkalemia (potassium of 5.8) and an elevated b-type natriuretic peptide (BNP) level of 7901. The patient's chest X-ray was consistent with pulmonary edema. The patient was admitted and treated for congestive heart failure (CHF). The patient's echocardiogram demonstrated left ventricular ejection fraction (LVEF) of 50% with left ventricular (LV) apical hypokinesis, right ventricular dilatation and pulmonary hypertension. The patient's electrocardiogram (EKG) revealed sinus rhythm with right bundle branch block and left anterior hemiblock.  The patient was treated with diuretics, and the patient's potassium normalized.  The patient's right-sided heart failure was thought to be due to morbid obesity and probable obstructive sleep apnea (OSA) rather than acute on chronic PE, as the patient was on oral anticoagulant therapy for a few years.  The patient was ultimately discharged three days after presentation.

Based on the review of the medical record and literature, inpatient hospital admission was medically necessary for this patient. This patient presented with lethargy and lightheadedness and had recently been released from the ED after presenting with similar symptoms.  On physical examination, the patient was fluid overloaded and had pedal edema. The patient's laboratory testing revealed an elevated BNP level and prominent pulmonary vasculature with on chest X-ray.  The patient was diagnosed with both right- and left-sided heart failure. The patient responded to diuresis and was released after several days of treatment.  As per literature, failure to admit and treat this patient would have resulted in excess morbidity or even mortality.  As per Lassus et al. (2013), patients with chronic congestive heart failure and renal insufficiency have a high risk of adverse outcomes warranting a higher level of care.  In one study, patients presenting with congestive heart failure and an elevated BNP level (greater than 200pg/ml(picograms per milliliter)) were found to have an increased morbidity and mortality in the subsequent 90 days (Maisel et al., 2004). 

In conclusion, the patient had decompensated CHF and responded to IV diuretic therapy. Management in the hospital at an acute level of care was warranted. 

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

The insurer's denial of coverage for the inpatient hospital admission at an acute level of care should be reversed. The medical necessity is substantiated.