Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dyspnea, Orthopnea, Congestive Heart Failure
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The health plan's determination is upheld.

The patient is a female who presented to the emergency department (ED) with a dry cough and shortness of breath. The patient reported that two weeks ago, her and her daughter were sick with a cold. She suffered from a persistent dry cough and developed slowly progressing shortness of breath. Her shortness of breath was worse in the supine position and improved after the patient sat up. Her dyspnea was not exertional. Her cough was nonproductive.

The patient has a medical history of atrial fibrillation (on Eliquis), heart failure with preserved ejection fraction (HFpEF), hypertension (HTN), hyperlipidemia (HLD), diabetes mellitus (DM) and hypothyroidism. In the ED, her blood pressure (BP) was 167/67, her heart rate (HR) was 76 beats per minute (BPM), her temperature was 97.8 and her peripheral capillary oxygen saturation (SpO2) was 94 percent (%). She was not in acute distress and her lungs were clear to auscultation (CTA).

Her heart was irregularly irregular. Her abdomen was soft with positive bowel sounds (BS). She did not have lower extremity (LE) edema. Her electrocardiogram (ECG) revealed atrial fibrillation with flattened ventricular repolarization (T) waves. Her laboratory studies revealed a potassium of 5.2, her troponin was 0.02. and her brain (or B-type) natriuretic peptide (BNP) was 182. Her Coronavirus (COVID) test was positive. 
The patient was admitted to the hospital. She was treated with intravenous (IV) Lasix. The patient underwent an echocardiogram. It revealed severe left atrial dilatation, normal left ventricular (LV) size with no evidence of left ventricular hypertrophy. There was severe right atrial dilatation, normal right ventricle (RV) size and the aortic valve was calcified without stenosis. She had pulmonary hypertension with estimated pulmonary artery (PA) pressures of 49 millimeters of mercury (mmHG).

Her condition had improved. Her admitting provider felt that there were no indications for continued IV Lasix. She was switched to oral Lasix. An infectious disease (ID) consultation was obtained, and it was noted that the patient did not have indications for Remdesivir or steroids. She was treated with nebulizers and cough suppressants. She was diagnosed with COVID bronchitis. Her Insulin dose was adjusted. Her atrial fibrillation was treated with rate control, beta blockers and anticoagulation. 

The requested health service/treatment of an inpatient hospital admission was not medically necessary for this patient. The patient presented with progressive dyspnea on exertion and was diagnosed with congestive heart failure. However, her BNP was mildly elevated at 182 and her chest x-ray (CXR) revealed mild congestion. The patient responded to IV Lasix well and improved after one dose of IV Lasix. She subsequently was maintained on oral Lasix. Her echocardiogram was remarkable for elevated pulmonary artery pressure, but that could have been chronic.

The patient also had a positive COVID test, but she suffered a mild form. She was not hypoxemic, she did not have fever or severe dyspnea, and there was no significant CXR suggestive of COVID pneumonia. The patient did not receive IV Remdesivir or steroids because it was not medically necessary. The patient's cardiac and respiratory status remained stable, there were no indications for IV medications. Her condition improved, and she was treated with oral medications and inhalers. The patient's condition and her management did not meet criteria for inpatient admission. An alternate level of care would be more appropriate.

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