Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a male. He was hospitalized for CHF (congestive heart failure). He presented to the emergency department for evaluation of shortness of breath x2 days and worsening bilateral leg edema for two weeks. His past medical history is pertinent for diabetes, hypertension, morbid obesity, gastric bypass, hernia repair and anemia.

The patient's vital signs were stable: BP (blood pressure) 159/88, O2 (oxygen) saturation 94% on room air, pulse 94, temperature 100.8 and weight 320 pounds. CV (cardiovascular) exam revealed rhonchi, accessory muscle use, but RR (respiration rate) 17, and bilateral lower leg edema.

By day three, the patient was seen by Cardiology. The clinical impression was diastolic heart failure and treatment included daily IV (intravenous) furosemide. EKG (electrocardiogram) revealed sinus rhythm with PVCs (premature ventricular contractions). Chest film reported mild diffuse lung haziness may be related to overlying soft tissue body habitus. Echocardiogram reported low normal ejection fraction and grade 3 diastolic dysfunction with increased left atrial pressure. BNP (brain natriuretic peptide) was elevated to 406. Infectious Disease was consulted and he received IV (intravenous) antibiotic to cover for pneumonia.

By day four, chest the CTA (Computed Tomographic Angiography) showed no PE (pulmonary embolism). WBC (white blood count) was 11.6.

By day five, the paitnet was deemed stable for discharge to home. This is an appeal of the denied claim the requested Acute Inpatient Hospital Stay was medically necessary for this patient.

No, the Inpatient admission was not medically necessary.
Based on the peer reviewed medical literature, the documentation submitted for review do not establish the requested Acute Inpatient Hospital Stay was medically necessary for this patient. According to the MCG (Milliman Care Guidelines) Guidelines titled: Heart Failure (ORG: M-190), the inpatient admission was not medically necessary, because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay per the guideline. Criteria for inpatient stay are not met, including documentation of hemodynamic instability, respiratory distress, change in mental status, severe heart failure, cardiac arrhythmias of immediate concern, myocardial ischemia or myocardial infarction, positive troponin not explained by CKD (chronic kidney disease) and CHF (congestive heart failure) , hypertension requiring inpatient hospitalization, CVA (cerebrovascular accident), pulmonary embolism, aortic dissection, severe electrolyte abnormalities or any other medical condition or other medical instability or acute care needs for which emergency and observation care have failed or are not considered appropriate and that would require acute inpatient management. The care he received for mildly decompensated chronic LV (left ventricle) systolic HF (heart failure) is routinely provided safely and effectively at a lower level of care. Hospitalization for patient, physician or hospital convenience does not establish medical necessity. The denial for care in the acute setting should be upheld when the same care can be provided in a lesser intense setting and lower level of care.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.