Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Congestive Heart Failure. 
Treatment: Inpatient Hospital. 

The insurer denied coverage for inpatient hospital. 

The denial is upheld. 

This is the case of a male patient with a past medical history of hypertension, coronary artery disease, bipolar, depression, hepatitis A, goiter, and prediabetes. The patient was brought in by ambulance from home for shortness of breath (SOB). The patient had stopped smoking 2 weeks before the presentation and had since started feeling SOB. He had a long smoking history of 1 pack per day since at an early age. The patient had heart palpitations (racing) and dizziness with activity. He was positive for lightheadedness. The physical examination revealed blood pressure was 119/89 and saturations on room air were 99% (percent). The patient was not in acute distress. He had a regular rate and rhythm and normal heart sounds. Pulmonary effort was normal. There was no respiratory distress. There were normal breath sounds. The general comments included SOB on exertion/abnormal electrocardiogram (EKG)/uncontrolled hypertension, with differential diagnoses of acute coronary syndrome (ACS), cardiomyopathy, congestive heart failure (CHF), or cardiac arrhythmia. The patient was to be admitted to telemetry and was noted to be stable on admission. The chest x-ray was reviewed and revealed cardiomegaly with concern for CHF. The EKG had revealed sinus rhythm with many premature ventricular contractions (PVCs) questionable anterior infarct and prolonged QTc (measurement on electrocardiogram) interval. The transthoracic echocardiogram (TTE) revealed the left ventricle was severely dilated and systolic function was severely and globally reduced. The left ventricular ejection fraction (LVEF) was less than 10%. The apex was poorly visualized. It was recommended a limited contrast study to assess for apical thrombus. There was moderate mitral valve regurgitation. The patient was treated with intravenous (IV) Lasix. He underwent a left heart catheterization (LHC) showing minimal non-obstructive coronary disease. The patient had spontaneous atrial tachycardia likely triggered by PVCs. He underwent an Electrophysiology (EP) and Cardiology consultation. The patient was discharged in stable condition. 

Inpatient criteria was not met for new onset CHF and appropriate EP and Cardiology consultants. An inpatient admission was not appropriate. 

A patient with CHF should be admitted to the hospital if any of the following criteria are present: 

- Respiratory distress (respiratory rate > [more than] 40 breaths per minute) or pulmonary edema (determined by radiograph) 
- Hypoxia (oxygen saturation < 90%) 
- Anasarca or significant edema (>= [more than of equal to] +2). 

These were not present per the documentation. The patient could have been evaluated during an observation level of care. 

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

The inpatient admission was not considered medically necessary for this patient. 

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical necessity is not substantiated.