Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dyspnea on exertion.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

This male was hospitalized for a congestive heart failure (CHF) exacerbation. He presented to the emergency department for evaluation of worsening dyspnea on exertion, in the setting of stopping his Lasix one week prior. His past medical history was significant for chronic congestive heart failure from heart failure with reduced ejection fraction (HFrEF) with an ejection fraction (EF) of 45% by a transthoracic echocardiogram (TTE), atrial flutter, chronic anticoagulation with Eliquis, hypertension, medical noncompliance and polysubstance abuse, including daily crack cocaine use.  

The patient's vitals revealed a heart rate of 113-119, respiratory rate of 24-30, blood pressure of 116/104, and oxygen (O2) saturation of 93% on room air (RA).  The patient's physical exam revealed moderate shortness of breath, inspiratory wheezes, rales at the bases, pro-b-type and p-type natriuretic peptides elevated to 5479, and an electrocardiogram (EKG) showing atrial flutter with a ventricular rate of 117, with ST depression in the inferior leads.  The patient's chest x-ray showed cardiomegaly.  His echocardiogram revealed a left ventricular ejection fraction (LVEF) of 20-25%. 

Treatment included intravenous metoprolol, intravenous digoxin, intravenous Lasix, and referral to a substance abuse counselor. The patient demonstrated good diuresis, lungs became clear and he was discharged to inpatient drug rehabilitation. 

This is an appeal to the medical necessity of the acute inpatient hospital stay for this patient.

No, the proposed acute inpatient hospital admission was not medically necessary.

Based on the peer-reviewed medical literature and expert medical opinion, the documentation submitted for review does not establish the requested acute inpatient hospital stay was medically necessary for this patient. According to the Milliman Care Guidelines (MCG) titled: Heart Failure (ORG: M-190), inpatient admission was not medically necessary, because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay per the guideline. Criteria for an inpatient stay are not met, including documentation of hemodynamic instability, respiratory distress, change in mental status, severe heart failure, cardiac arrhythmias of immediate concern, myocardial ischemia or myocardial infarction, positive troponin not explained by chronic kidney disease (CKD) and congestive heart failure (CHF), hypertension requiring inpatient hospitalization, cerebral vascular accident (CVA), pulmonary embolism (PE), aortic dissection, pneumonia, severe electrolyte abnormalities or any other medical condition or other medical instability or acute care needs for which emergency and observation care have failed or are not considered appropriate and that would require acute inpatient management. There was no clinical decline or inadequate response to treatment which required continuation of the hospital stay past the observation period. 

The care the patient received for uncomplicated, mildly decompensated chronic left ventricular ejection fraction (LV) systolic heart failure (HF) from medical noncompliance is routinely provided safely and effectively at a lower level of care. Hospitalization for patient, physician, or hospital convenience does not establish medical necessity and therefore the denial is upheld for care in the acute setting when the same care can be provided in a lesser intense setting.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.

There was no clinical decline or inadequate response to treatment which required continuation of the hospital stay past the observation period. The care the patient received for uncomplicated, mildly decompensated chronic left ventricular function (LV) systolic heart failure (HF) from medical noncompliance is routinely provided safely and effectively at a lower level of care.