Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Decompensated Heart Failure

Treatment: inpatient emergency

The insurer denied coverage for inpatient emergency

The denial is upheld

The patient is an adult with multiple medical issues who presented to the emergency department (ED) with complaint of shortness of breath (SOB), nausea, vomiting and diarrhea. The patient's past medical history (PMH) included hypertension (HTN), hyperlipidemia (HLD), epilepsy (On Depakote and Lacosamide), atrial fibrillation, valve replacement on anticoagulants, congestive heart failure (CHF), coronary artery disease (CAD), status post (S/P) coronary artery bypass graft (CABG), cerebrovascular accident (CVA), and chronic kidney disease (CKD).

At presentation, vital signs were temperature 97.3 degrees F (Fahrenheit), heart rate 103, blood pressure 129/91 mmHg (millimeters of mercury), respiratory rate 15, and oxygen (O2) saturation 100% (percent). The patient was in no acute distress (NAD). Lungs were clear. Cardiovascular system were normal.  Abdomen was soft, non-tender (NT). The patient was alert and oriented x3 (person, place, and time) with a non-focal neuro exam. The patient was given intravenous (IV) Lasix 80 mg (milligrams), and magnesium. The patient was also given BP medications. The patient developed a seizure-like episode. The patient had reported noncompliance with seizure medications. White blood cell count (WBC) was 5.2, hemoglobin 10.9, electrolytes within normal limits (WNL) blood urea nitrogen / creatinine 29/1.4.  The patient was loaded on antiseizure medications. Chest x-ray (CXR) was essentially normal, with possible small left effusion. Echocardiogram revealed left ventricular ejection fraction of 15%. Troponin was 0.18 Brain natriuretic peptide was 4857.

The patient was admitted for decompensated heart failure. The patient was continued on Lasix 40 mg twice daily. Cardiac meds were restarted. The patient's international normalized ratio (INR) had increased to 5 and anticoagulants (AC) were held. It returned back to normal the next day and the patient was restarted on AC. The patient was seen by Cardiology. The patient was afebrile and hemodynamically (HD) stable.  Troponins trended lower, it was elevated due to demand ischemia. The patient had no electrocardiogram (EKG) changes and did not complain about chest pain. The patient was euvolemic and recommended to start maintenance oral (PO) Lasix doses and other cardiac medications.  A Doppler study was done which ruled out peripheral arterial disease (PAD) and deep vein thrombosis (DVT).

This patient remained stable after admission. The patient was placed back on maintenance medications and discharged home on PO medications. This patient did not need acute inpatient hospitalization. The patient had developed some symptoms as they had been non-compliant with medications. The patient could have been placed on observation status which could last for up to 48 hours while diagnostic testing and treatment were initiated. The patient was evaluated by Cardiology and Neurology. Possible seizures were also secondary to noncompliance with meds with sub therapeutic drug levels.

Based on the above, the insurer's denial must be upheld.   The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient emergency admission is not substantiated.