Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart Failure

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This is a patient with a past medical history that includes stroke (CVA), hypertension (HTN), heart failure with reduced ejection fraction (HFrEF) with ejection fraction of 35%, illicit drug use, thoracic aneurysm with intramural hematoma, asthma, emphysematous changes on chest x-ray, depression, remote tobacco abuse, and medication non-compliance. The patient presented to the Montefiore Hospital emergency department (ED) noting one week of dyspnea. The patient had not been taking their medications following the death of their mother.

The patient was evaluated in the ED. A recent 5-day admission less than a month earlier for hypertensive urgency and heart failure (HF) exacerbation was noted. HF exacerbation and shortness of breath were diagnosed. The patient was mildly hypertensive, with systolic blood pressures in the 140s. Troponins were abnormal at 0.14 (subsequently improved to 0.12 and 0.11). Brain natriuretic peptide (BNP) was elevated at 2114. Chest x-ray showed interstitial edema. The patient was diuresed with two separate doses of intravenous (IV) Lasix 40 milligrams (mg), which led to improvement in the patient's symptoms, but also to a new pre-renal acute kidney injury (AKI) and relative hypotension, with systolic blood pressures around 100. Exam included rales. An electrocardiogram (EKG) showed sinus rhythm with inverted T waves in the lateral leads, prolonged QT, and left ventricular hypertrophy (LVH) with strain. The patient admitted to recent marijuana use but denied recent cocaine. Urine toxicology was positive for cocaine. Admission to telemetry was planned.

The patient's home medications were held, which led to improvement in their creatinine from 1.35 to 1.1, and soon the patient was started on a more appropriate drug regimen and was ultimately discharged to home.

At the time of admission, the patient's troponin was consistent with myocardial infarction (MI),  specifically a Type 2 MI, as no indication of active coronary thrombus was identified in this case.  Based on the Milliman Care Guidelines (MCG) criteria outlined by Drs Felzenberg and Hammond,  the troponin level of 0.51 nanograms (ng)/milliliters (mL) constitutes "Acute myocardial ischemia (heart attack) causing or associated with failure." Additionally, the patient's glomerular filtration rate (GFR) of 59 was consistent with a 33% drop from normal (using 90 or above as normal), which represents "Progressively (ongoing) rising creatinine (continued increase in kidney function levels) with reduction of more than 25% in estimated glomerular filtration rate (kidney function levels) from baseline." This was another of the listed criteria that would have warranted approval for the admission, based on Healthfirst's referenced guideline.

Inpatient admission was medically necessary for the patient, for the reasons outlined in the previous response. Specifically, the patient's elevated troponin and AKI both met Healthfirst's threshold, as set forth in the denials. The patient's risk was additionally elevated by multiple factors, including medication non-compliance.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an inpatient admission is substantiated.