Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory Problems - Congestive Heart Failure/CHF
Inpatient Hospital

The patient is a male with a past medical history significant for chronic obstructive pulmonary disease, heart failure with reduced ejection fraction secondary to nonischemic cardiomyopathy, status post implantable cardioverter defibrillator (ICD) implantation, atrial flutter being anticoagulated with warfarin, diabetes mellitus type 2, hypertension, and obstructive sleep apnea. He presented to the emergency department with complaints of shortness of breath, which started approximately one day before the day of admission. 

Upon initial evaluation in the emergency department, the patient was suspected to have symptoms of volume overload and acute on chronic decompensated heart failure.
Reportedly, the patient was lifting heavy trash cans at work and started to experience palpitations that were associated with shortness of breath. The review of systems was positive for shortness of breath, palpitations. The rest of the review of systems was negative. 

On the physical exam, the patient was afebrile, blood pressure was 130/87, pulse rate 78, respiratory rate 19, oxygen saturation 97% on room air. The patient's head, eyes, ears, nose, throat (HEENT) exam was unremarkable. He was slightly tachypneic but was able to speak 5-6-word sentences. He had normal heart sounds but irregular rhythm. The rest of the physical exam was unremarkable. The laboratory evaluation revealed that the patient's white blood cell count was 8.7, hemoglobin 13.4, hematocrit 40.3, platelets 192. Sodium was 139, potassium 4.6, chloride 100, bicarbonate 24, blood urea nitrogen (BUN) 22, creatinine 1.2, glucose 187. Troponin was 0.043. Venous blood gas was obtained and appeared to be within normal limits. The patient's brain natriuretic peptide (BNP) was severely elevated at 6740. 

The patient was admitted to the hospital with a diagnosis of acute on chronic systolic and diastolic congestive heart failure (CHF). The patient received treatment with intravenous Lasix, with improvement in his clinical symptoms. In the hospital, the patient was seen by a cardiologist who recommended switching the patient's diuretics to Bumex prior to the discharge. 

The patient was provided counseling in regard to adherence to a low sodium diet.
Another clinical problem was an atrial flutter. It was mentioned in the discharge summary that the patient's rate was controlled. Because his international normalized ratio (INR) was supratherapeutic, one dose of warfarin was held. The patient was recommended to continue to follow up with the Coumadin clinic as an outpatient. It was mentioned that the patient carried a diagnosis of chronic obstructive pulmonary disease, but there was low suspicion for chronic obstructive pulmonary disease (COPD) exacerbation at the time of admission. 

Since the patient's condition improved, he was discharged home.

The health plan's determination is upheld.

The requested health service/treatment of inpatient stay was not medically necessary for this patient at the acute inpatient level of care, primarily because of the relatively mild severity of the COPD exacerbation and the fact that the patient's condition improved within a relatively short period of time after initiation of the treatment.  Admission for monitoring was definitely appropriate to ensure hemodynamic stability and response to treatment. 

This patient remained hemodynamically stable and had no severe electrolyte abnormalities or cardiac arrhythmias of immediate concern. There was no evidence that the patient had any precipitating factors for acute CHF. There was no evidence that the patient had acute coronary syndrome. A mildly elevated troponin level was most likely related to acute CHF rather than an acute coronary syndrome. Pulmonary edema was not severe and did not require the use of invasive or noninvasive assisted ventilation. The patient's tachypnea improved fairly quickly. Taking into consideration all these facts, it was clear that the patient had mild CHF exacerbation, which was treated very effectively within a short period of time. 

The patient did not require admission at the inpatient level of care based on nationally recognized criteria for inpatient admission. Based on the MCG criteria, for heart failure, the inpatient level of care is usually recommended in cases of acute CHF in the setting of an acute coronary syndrome, severe pulmonary edema requiring invasive or noninvasive assisted ventilation, severe or persistent tachypnea, altered mental status, acute kidney failure. The review of the medical records demonstrated that the patient had none of the circumstances listed above. There were no additional unstable medical conditions documented in this clinical case that would justify admission at the acute inpatient level of care based on the standards of care accepted in the United States.