Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestive heart failure (CHF)

Treatment: Inpatient admission

The insurer denied coverage for an inpatient admission

The denial is overturned

This is a man with a past medical history that includes medical non-compliance, coronary artery disease with non-ST (interval on an echocardiogram) elevation myocardial infarction (NSTEMI), cardiomyopathy with ejection fraction of 30%, heart failure with reduced ejection fraction, diabetes, renal artery stenosis, cerebrovascular accident, hypertension, hyperlipidemia, obesity, obstructive sleep apnea, asthma, gastroesophageal reflux disease, gout, chronic small bowel obstruction, inguinal hernia, hemorrhoids, osteoarthritis, goiter, anxiety, and hypothyroidism. 

At the time of his admission, despite indications in his medical record that his elevated troponin was "baseline" and that there was "no evidence of ACS (acute coronary syndrome)", a troponin of this level is consistent with myocardial infarction (MI),  specifically a Type 2 MI, as no indication of active coronary thrombus was identified in this case.  Based on the MCG (Milliman Care Guidelines) criteria, the troponin level of 0.51 ng(nanograms)/mL (milliliter) constitutes "evidence of a heart attack by bloodwork or heart racing." During his prior admission, NSTEMI was diagnosed based on very similar bloodwork (troponin of 0.57 at that time, with troponin of 0.51 at the time of this admission).

Additionally, hospitalization was appropriate in this case, regardless of the presence or absence of MI. The UpToDate pathway for assessing heart failure in the emergency department indicates that in the setting of ACS, admission for treatment of ACS is indicated. If ACS is not present but troponin is elevated, admission to telemetry is warranted. Even if troponin is not elevated, admission is warranted for "concerns about treatment adherence, home supports, or ability to return to ED (emergency department)."  The patient meets each of these criteria.

UpToDate.com also indicates that "...clinical features that generally indicate need for hospital-level evaluation and care include...New HF (heart failure) or change in HF...severe, progressive dyspnea with minimal exertion, even if not dyspneic at rest ...elevated troponin levels in the absence of ACS ...history of non-adherence to therapy."  The patient also meets each of these criteria. This is not an exhaustive list; he does not meet every criterion, but any of the above is an independent threshold that he has crossed. Regarding the mention of "New HF or change in HF," it is indicated in the clinical notes that there had been no prior hospitalizations for heart failure, and his progressive dyspnea on exertion is documented in multiple locations.

Close monitoring is appropriate in managing acute decompensated heart failure, due to the high risk of hemodynamic instability in these patients. 

His non-compliance, and often oppositional posture, is thoroughly documented in the medical record as submitted for review. Unfortunately, his decision-making portends a poor prognosis for the patient, and also significantly increases his risk for an acute event. 

The inpatient admission was medically necessary for this patient for the reasons outlined above. Specifically, he did meet criteria for inpatient treatment under MCG 25 guidelines, with an elevated troponin consistent with Type 2 MI. He also had multiple additional indications, including his impressive non-compliance and failure to properly manage his medical conditions as an outpatient. 

This is consistent with the documentation submitted for review.

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

The insurer's denial of coverage for inpatient admission is overturned. Medical Necessity is substantiated.