Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Heart Problem.
Treatment: Hospital admission.
The health plan denied: Hospital admission.
The determination is: Overturned. 

The patient is a male with a past medical history significant for chronic systolic heart failure due to nonischemic cardiomyopathy status/post (s/p) implantable cardioverter defibrillator (ICD) placement, coronary artery disease (CAD) s/p percutaneous coronary intervention (PCI), CardioMEMS implant placement, chronic kidney disease (CKD) stage 3, chronic obstructive pulmonary disease (COPD), obstructive sleep apnea (OSA) not compliant with continuous positive airway pressure (CPAP) therapy, and hypertension. He was brought to the emergency department (ED) by Emergency Medical Services (EMS) for evaluation of worsening shortness of breath. On physical examination, the patient demonstrated conversational dyspnea with evidence of fluid volume overload. His chest x-ray (CXR) demonstrated pulmonary edema. His B-type natriuretic peptide (BNP) was significantly elevated at 3,490. He was given Lasix 40 milligrams (mg) intravenous (IV) in the ED along with nebulizer treatments and IV steroids.
The patient was admitted to telemetry services under an inpatient level of care for evaluation and treatment of acute chronic heart failure with volume overload and COPD (Chronic obstructive pulmonary disease) exacerbation. Cardiology and pulmonary services were consulted. The patient was continued on IV Lasix twice daily, as well as steroids and nebulizer treatments. Due to persistent signs and symptoms of acute heart failure, the patient's IV Lasix dose was increased, and Diamox was added for increased diuresis. His echocardiogram demonstrated severely reduced left ventricular ejection fraction (LVEF), dilated left ventricular (LV) restrictive filling pattern, moderate to severe mitral regurgitation (MR), moderate tricuspid regurgitation (TR) consistent with advanced systolic heart failure and acute decompensated heart failure (ADHF). Telemetry monitoring demonstrated multiple runs of non-sustained ventricular tachycardia (NSVT). His ICD was interrogated, demonstrating normal device function. After adequate IV diuresis and symptom improvement, the patient was discharged home.
At issue is the medical necessity of hospital admission.
The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of inpatient admission was medically necessary, appropriate, and in the best interest of the safety of this patient. Due to the patient's high-risk presentation of acute heart failure with significant volume overload highlighted by conversational dyspnea and pulmonary edema along with high-risk markers of an elevated BNP (B-type Natriuretic Peptide) and runs of ventricular tachycardia (VT), The treating provider's decision to admit the patient under inpatient level of care given hospital care services would be needed for greater than 2 midnights. Furthermore, due to the high level of medical complexity of this patient's acute heart failure presentation and the need for escalation of IV diuretic regimen due to persistent signs and symptoms of volume overload, inpatient level of care would be recommended by peer-reviewed medical literature and expert consensus guidelines on acute heart failure management [1-5].