Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Congestive Heart Failure. 
Treatment: Inpatient Hospital Admission. 
The insurer is denied coverage for Inpatient Hospital Admission. 
The denial is Upheld. 

This male patient has a history of hypertension (HTN), anxiety, cerebrovascular accident (CVA), depression, hyperlipidemia (HLD), diabetes mellitus (DM), and congestive heart failure (CHF), peripheral vascular disease (PVD) status post below-knee amputation (BKA).  He was brought to the hospital with complaints of shortness of breath (SOB).  The patient complained of some cough on and off.  He denied fever, chills or chest pain.  He had a positive COVID test on the week before arrival. The patient's subsequent test was negative. In the Emergency Department (ED) the patient was afebrile with a blood pressure of 120/62, respiratory rate of 18, and oxygen saturation of 98%. The physical exam was unremarkable.  The patient's lungs were clear, and cardiovascular system was normal. White blood cell (WBC) count was 5.3, hemoglobin was 11.8, B-type natriuretic peptide (BNP) was 2340, and creatine kinase MB Isoenzyme (CK-MB) was normal. A chest X-ray showed congestive changes.  The COVID-19 test was negative.  D-Dimer(blood test that can be used to help rule out the presence of a serious blood clot) level was unremarkable. He was treated with Lasix in the ED and was then admitted to the hospital for decompensated heart failure (HF). The patient was afebrile and hemodynamically stable.  He was sitting comfortably in bed and was speaking full sentences. A computed tomography (CT) scan of the chest revealed ground-glass opacity (GGO); congestion versus inflammatory changes. There was no pulmonary embolism (PE) noted. The admission diagnosis was a Systolic CHF Exacerbation.  He was treated with intravenous (IV) Lasix.  The patient was continued on maintenance cardiac medications and insulin. He improved with treatment.  Cardiology and pulmonary consultations were done. Pulmonary service felt that the patient did not have pneumonia.  The patient had no fever or leukocytosis. Chest imaging was consistent with congestive changes.  Myocardial infarction (MI) was also ruled out. Cardiology service recommended treatment for CHF and follow-up as an outpatient for his mitral valve disorder.  The patient was seen by Physical Medicine and Rehabilitation who recommended discharge with outpatient therapy.

Based on the review of the medical record and literature, an inpatient admission was not medically necessary for this patient. The patient remained stable after admission and was discharged home the next day on oral (PO) medications with outpatient follow up. This patient did not need an acute inpatient hospitalization.  He could have been placed on observation status while diagnostic testing and treatment were initiated.  As per literature review, patients can remain in Observation for up to 48 hours.  In this case, the patient did not have an acute pneumonia.  The patient's HF was mild.  The patient responded to IV Lasix in the ED. The patient's COVID-19 test was negative. The patient was stable to be discharged home after a period in observation status on PO medications with close follow-up in an outpatient setting.  If needed home oxygen could have been ordered.  

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital admission should be upheld.  The medical necessity is not substantiated.