Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems/Congestive Heart Failure
Treatment: Inpatient Hospital
The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is overturned.

The patient is a man with a past medical history of hypertension, hyperlipidemia, diabetes, coronary artery disease, ischemic cardiomyopathy and chronic kidney disease. He presented to the emergency department for evaluation of generalized weakness, headaches, left sided chest pain, nausea, vomiting, and diarrhea. On arrival to the emergency department (ED), his initial blood pressure was 81/53 millimeters of mercury (mmHg) with a heart rate of 94 beats per minute and a respiratory rate of 20 breaths per minute. His oxygen saturation was 99% on room air. An initial electrocardiogram (EKG) showed normal sinus rhythm with a right bundle branch block. A chest x-ray did not demonstrate any cute cardiopulmonary abnormalities. Initial laboratory work up was notable for a brain (or B-type) natriuretic peptide (BNP) of 875, a troponin of 0.054, a lactate of 2.37, a glucose of 104, a blood urea nitrogen (BUN) of 49, a creatinine of 1.96, an alanine aminotransferase (ALT) of 55, a C-reactive protein (CRP) of 12.5, a D-dimer of 0.94, and a phosphorus of 4.6. The patient was bolused with intravenous (IV) fluids in the ED and was admitted to the inpatient unit for management of an acute on chronic systolic heart failure exacerbation, acute on chronic renal failure, cardiogenic shock and diabetes. He was evaluated by the cardiology team and per their assessment, he has end stage heart failure with very low cardiac output including worsening cachexia. They recommended evaluation by nephrology and the advanced heart failure team for advanced therapies. He was seen by nephrology, and they attributed his renal failure to cardio-renal syndrome, and they recommended transfer to another facility for further care. During the hospitalization, the patient had hypoglycemic episodes and had hyperkalemia which was treated with Kayexalate. He also had episodes of tachypnea and tachycardia requiring supplemental oxygenation. Ultimately, the patient was transferred for further care.

At issue is the medical necessity for the inpatient stay.

The health plan's determination of medical necessity is overturned, in whole.

Yes, the inpatient admission was medically necessary. This is a patient with multiple co-morbidities including severe cardiomyopathy, chronic kidney disease, and coronary artery disease who presented with weakness, chest pain, nausea, and vomiting. He was hemodynamically unstable with a systolic blood pressure in the 80's mmHg and there was objective evidence of end organ malperfusion as evident by an elevated lactic acid level. Furthermore, he had elevated cardiac biomarkers (including troponins) and acute on chronic kidney injury with evidence of hyperkalemia. All of this, in a patient with known severe cardiomyopathy, is concerning for cardiogenic shock due to decompensated heart failure resulting in multi-system organ failure. Patients who are in shock with such tenuous hemodynamic status need close monitoring and treatment in the inpatient setting. Observation or outpatient management of this patient would not have been appropriate.