Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory System/ Cough/ Cough, swelling in legs
Treatment: Inpatient Hospital/ Inpatient emergency admission
The health plan has denied the requested treatment, inpatient emergency admission, as not medically necessary. The health plan's determination is overturned.

This case involves a male with a past medical history significant for chronic heart failure, hypertension, cocaine abuse, chronic obstructive pulmonary disease (COPD), and an active smoker who presented to the emergency department (ED) for evaluation of worsening leg swelling extending to his thighs, cough, and shortness of breath for 4 days. In the ED, the patient's blood pressure (BP) was severely elevated to 172/126 millimeters of mercury (mmHg), he was hypoxic to 89 percent (%) on room air (RA) and was tachypneic. Notable laboratory studies revealed elevated creatine kinase (CK) (677) and a high cardiac troponin at 58 nanograms per liter (ng/L). A chest x-ray (CXR) showed pulmonary edema with bilateral pleural effusions. The patient was given Lasix 60 milligrams (mg) intravenous (IV) in the ED for diuresis and Procardia 60 mg daily for treatment of uncontrolled hypertension (HTN). The patient was admitted to the telemetry service under an inpatient level of care for evaluation and treatment of acute heart failure associated with a hypertensive emergency, acute kidney injury (AKI), transaminitis, atrial flutter, and cocaine abuse. The patient was monitored on telemetry, diuresed with Lasix 40 mg IV twice daily, laboratory studies were serially assessed monitoring his renal and hepatic parameters, and he required oxygen supplementation for the relief of his dyspnea and hypoxia. He was evaluated for acute coronary syndrome (ACS). Cardiology service was consulted, and an echocardiogram was obtained showing a severely reduced left ventricular ejection fraction (LVEF) of 25-30%. A nuclear stress test was ordered for evaluation of potential ischemic cardiomyopathy (the report of results was not provided for this review).

At issue is the medical necessity for an Inpatient emergency admission.

I recommend that the health plan's determination be overturned, in whole.

An inpatient admission for the treatment of acute heart failure associated with a hypertensive emergency and acute myocardial, renal, liver, and pulmonary failure, was medically appropriate, necessary, and in the best interest for the safety of this patient.
The patient presented with acute decompensated heart failure associated with multiple high-risk features including hypertensive emergency, high cardiac troponin consistent with acute myocardial injury, hypoxia and pulmonary edema associated with short-term adverse cardiac events including acute myocardial infarction (MI) and mortality. In addition, there was also evidence of acute renal and hepatic injury attributed to acute heart failure which are also high-risk poor-prognostic markers. The patient required aggressive intravenous (IV) diuresis due to persistent volume overload beyond the observation level of care time frame to achieve adequate decongestion and improvement of hypoxia and relief of dyspnea. Given the above combination of high risk features associated with this patient's acute decompensated heart failure exacerbation and prolonged need for aggressive IV diuresis due to significant volume overload, an inpatient level of care was medically necessary, appropriate, and in the best interest for the safety of the patient. This is supported by peer reviewed medical literature and expert consensus guidelines on acute heart failure management. [1-5]