Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Congestive heart failure, Shortness of Breath

Treatment: Inpatient admission

The insurer denied coverage for the inpatient admission.

The denial is upheld.

This is a female patient who presented to the Emergency Department (ED) with complaints of shortness of breath as well as wheezing, chest tightness and productive cough. The patient's past medical history was significant for sarcoidosis as well as anemia, asthma, coronary artery disease, diabetes, hyperlipidemia, hypothyroidism, and end-stage renal disease (dependent on dialysis). The patient's physical exam in the ED revealed scattered wheezing. The patient's vital signs revealed blood pressure of 162/64 with a pulse of 67 beats per minute; the patient had oxygen saturation at 91%. The patient received dialysis and had an arteriovenous (AV) fistula to the right bicep with an audible thrill. 

The physician indicated that the patient should undergo laboratory and diagnostic workup as her symptoms were concerning for a viral upper respiratory infection versus pneumonia versus asthma exacerbation. The patient's chest x-ray was stable with mild interstitial edema and no consolidation. The patient was given nebulizers as well as steroids. Upon reexamination, the patient was feeling better; however, she reported new chest pain. The physician detailed that the patient would likely need an admission for dialysis as well as serial enzymes and a cardiac work-up. 

The patient was admitted and was treated with continued intravenous (IV) medications. The patient was noted to have an elevated brain natriuretic peptide (BNP) lab level in the context of heart failure as well as a drop of hemoglobin. The patient's blood glucose was also noted to be increased; the physician attributed this to the use of steroids in the ED. The patient was noted to have oxygen saturation at 100% the following day with no significant abnormalities. There was trace wheezing and rhonchi on physical exam and the patient's electrocardiogram (EKG) revealed sinus rhythm at 69 beats per minute with left ventricular hypertrophy (LVH), and the question of lateral ischemia. The patient's troponin was noted to be 0.04 and hemoglobin was 8.3. The patient's blood urea nitrogen (BUN) was 42 and creatinine was 7.3. The recommendation was made to continue with treatment. The patient continued with treatment which included ongoing medications as well as hemodialysis. The patient also underwent multiple consultations and continued to clinically improve. The patient was able to transition to oral medications. The patient did not have any further significant adverse events throughout this patient's entire inpatient stay, and it was noted that given the period of stability, the patient was able to be discharged on day 9 of admission.

In this case, the patient presented with shortness of breath related to congestive heart failure. The patient had chest tightness and dry cough. The patient was treated with nebulizers, steroids with improvement in her symptoms. The patient's chest radiograph did not show florid acute pulmonary edema or pneumonia. There were no changes in mental status. There was no significant hypoxia. There was no danger of imminent respiratory failure. The patient could have been observed and treated up to 48 hours in the observational level of care. Severe medical problem warranting an inpatient admission was not established. 

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

The carrier's denial of coverage for the inpatient admission should be upheld. The medical necessity is not substantiated.