Appeal type: Medical necessity
Decision: Overturned

Dx: Cardiac/Circulatory Problems
Rx: Inpatient Hospital
Denied: Inpatient Hospital
Denial is overturned, in whole

The patient is a male with a history of obesity, chronic kidney disease, hyperlipidemia, chronic obstructive pulmonary disease (COPD), hypertension, diabetes and congestive heart failure with a left ventricular ejection fraction of 35%. He presented to the emergency department complaining of exertional dyspnea and lower extremity edema. He had recently been discharged from another hospital where he had been treated for decompensated heart failure and acute kidney injury. His blood pressure was 173/83 millimeters of mercury (mmHg) with a heart rate of 82 beats/minute. His respiratory rate was 20/minute with a room air oxygen saturation of 99%. On physical exam he had bibasilar rales and edema to his thighs. His blood urea nitrogen (BUN) was 44 milligrams per deciliter (mg/dl) with a creatinine of 2.2 mg/dl (baseline 1.8-2.1 mg/dl). His brain natriuretic peptide (BNP) level was 872 picograms per milliliter (pg/ml). His hematocrit was 31%. His electrocardiogram showed sinus rhythm with mild inferior ST segment depression. Chest X-ray showed no acute pathology. His serum troponin level was normal.

He was treated with intravenous furosemide and admitted to the hospital for management of decompensated heart failure. Intermittent intravenous furosemide was continued. The patient had persistent edema and rales. A continuous furosemide infusion was started. His creatinine level was 2.5 mg/dl. Cardiac catheterization was recommended but the patient was not deemed stable for the procedure. The following day the patient had continued rales and edema. The furosemide infusion was discontinued due to an increase in his creatinine level to 2.6 mg/dl. He had persistent rales and edema and was treated with intermittent intravenous and oral furosemide until the furosemide was held in anticipation of cardiac catheterization. His creatinine was 2.4 mg/dl. Cardiac catheterization showed three vessel disease. The patient was treated with furosemide post-catheterization. His creatinine had increased to 2.7 mg/dl. It was unchanged on the day of discharge and the patient was discharged home with plans for readmission for bypass graft surgery. Medical necessity for an inpatient admission is at issue.

The health plan's determination is overturned.

An inpatient stay was medically necessary. This patient presented with decompensated heart failure. He had recently been discharged from another hospital and had continued symptoms despite his hospitalization and subsequent outpatient management. He had evidence of acute kidney injury and when he failed to respond to intermittent doses of intravenous furosemide, required a continuous furosemide infusion. His furosemide treatment required frequent adjustments due to decreasing renal function. Cardiac catheterization was indicated but had to be postponed due to persistent pulmonary congestion and a rising serum creatinine level. The prolonged treatment this patient required, along with the need for frequent laboratory monitoring and medication adjustment, required an inpatient level of care.