Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Congestive heart failure
Treatment: Inpatient admission
The insurer denied Inpatient admission.
The denial is upheld.

The patient is an adult male. He was hospitalized for congestive heart failure (CHF). He presented to the emergency department (ED) with a three-day history of shortness of breath, cough, and hiccups. His past medical history is significant for known heart failure, two prior myocardial infarctions, ischemic cardiomyopathy (ICM), coronary stents treated with aspirin, and cerebrovascular accident (CVA). The clinical impression was acute on chronic congestive heart failure and atypical pneumonia. Vitals revealed tachycardia of 104 and tachypnea of 20-22. On examination, there were left basilar rales. The patient's labs were remarkable for elevated Troponin 68.30, NT-PROBNP (N-terminal pro b-type natriuretic peptide) 5,564.00, BUN (blood urea nitrogen) 29.8, Creatinine 1.6, Sodium 134, and Glomerular Filtration Rate 53.5. Chest computed tomography (CT) showed mild right upper lobe, left lower lobe infiltrates and mild emphysema. Chest X-ray showed borderline cardiac prominence. Electrocardiogram showed left atrial enlargement, left ventricular hypertrophy (LVH) with secondary repolarization abnormality and minimal ST elevation in the inferior leads. The patient's treatment included intravenous furosemide 40 milligrams, Entresto, spironolactone, and intravenous antibiotics. He was then admitted to inpatient level of care for further management. Pulmonology, Cardiology, and Infectious Disease consultations were obtained. 
Echocardiogram showed mildly dilated left ventricle, severe concentric left ventricular hypertrophy, moderate diastolic dysfunction (pseudonormal filling), moderately decreased left ventricular systolic function, significant regional wall motion abnormalities and left ventricle ejection fraction (LVEF) of 40% (percent).
The patient improved significantly during his hospital course and was discharged on day number (#) 4. The requested coverage for inpatient admission was denied coverage by the health plan as not medically necessary. The denial is being appealed.

The inpatient admission was not medically necessary.

Based on the peer-reviewed medical literature, including the MCG (Milliman Care Guidelines) Guidelines 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. Criteria for 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 CKD (chronic kidney disease) and CHF (congestive heart failure), hypertension requiring inpatient hospitalization, CVA (cerebrovascular accident), 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. In this particular case, there was no clinical decline or inadequate response to treatment which required inpatient hospitalization. The care that the patient received for mildly decompensated chronic LV (left ventricle) diastolic HF (heart failure) is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted information and the current published medical literature, the inpatient admission was not medically necessary. There was no clinical decline or inadequate response to treatment which required inpatient hospital care. The care he received for mildly decompensated chronic combined systolic and diastolic HF (heart failure) is routinely provided safely and effectively at a lower level of care. Therefore, the inpatient admission was not medically necessary.