Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of Breath, Chest Heaviness
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient presented to the emergency department (ED) with severe shortness of breath, leg swelling and chest heaviness. His pedal edema and pruritis started after he was put on Amikacin. The patient recently had been admitted to an outside hospital with pericarditis. He was diagnosed with ventricular septal defect (VSD) rupture and cardiac tamponade. The patient underwent VSD repair with drainage of pericardial effusion. The course was complicated by an infection with gram (Gm) positive bacteremia. It required home intravenous (IV) antibiotics. The patient was treated at home with imipenem and linezolid.
The patient later developed worsening bilateral lower extremity swelling and pruritis. The patient has a history of coronary artery disease (CAD), post percutaneous coronary intervention (PCI), hypertension (HTN), diabetes mellitus (DM) and congestive heart failure (CHF).
His most recent cardiac catheterization revealed an occluded right coronary artery (RCA) and patent coronary stent in the left circumflex (LCx).
There was an attempt to recanalize the RCA, but it was unsuccessful. He was referred to another facility and there the RCA was opened. The patient also had history of a radial arteriovenous (AV) fistula.
In the ED, his main complaint was pain in both feet, the left more than the right. The patient also complained of chest heaviness. It started after his cardiac surgery in June. There was no new pain, orthopnea or palpitations. His blood pressure (BP) upon presentation was 143/85, heart rate (HR) was 83 beats per minute (BPM), and oxygen saturation (O2 sat) was 98% on room air.
He was not in distress (according to postgraduate year 1 [PGY1] note, he was in mild distress.) In the ED, the patient had bilateral crackles in the lung bases with peripheral edema. (By another note, there was a normal cardiac and pulmonary exam). There was a thrill on the right radial pulse. His legs were swollen and his left foot was tender.
His hemoglobin (Hb) was 8.9, mean corpuscular volume (MCV) was 91.8, aspartate aminotransferase (AST) was 44, bilirubin was 1.5, albumin was 2.5. His venous blood gas revealed potential hydrogen (pH) 7.25 and partial pressure of carbon dioxide (pCO2) 61. Pro- brain (or B-type) natriuretic peptide (BNP) was 2319. That was higher than was higher than previously which at that time it was 2214. The troponin was normal.
The electrocardiogram (ECG) was unchanged when compared to a previous ECG. A chest x-ray (CXR) revealed severe cardiomegaly. There was no evidence of acute disease.
The echocardiogram revealed moderate left ventricular (LV) systolic dysfunction; moderate to severe inferior/ posterior hypokinesis. The left ventricular ejection fraction (LVEF) was 40%. There was a restrictive filling pattern consistent with severe diastolic dysfunction. There was mild left atrial dilatation. There was moderate right ventricular systolic function. There was mild to moderate tricuspid regurgitation and mitral regurgitation. The right ventricular systolic pressure (RVSP) was 60 millimeters of mercury (mmHg). There was severe pulmonary hypertension. There was moderate pericardial effusion. There was no pericardial tamponade. The patient was given IV furosemide.
The patient was admitted to the hospital. He was ordered intravenous (IV) Lasix. His previously obtained blood cultures in the outside hospital (OSH) revealed grow of Mycobacterium abscessus.
The plan was to admit the patient for diuresis, cardiology and vascular surgery consult. The patient was treated with IV diuretics. His lower extremity (LE) venous duplex was negative for a deep vein thrombosis (DVT). His arterial duplex of the right arm revealed an arteriovenous fistula between the radial artery and cephalic vein. There was no stenosis of any arm vessels. His LE arterial duplex revealed no significant arterial stenosis. the ankle brachial index was 1.47. It was likely falsely elevated due to calcified vessels.
The patient was consulted by infectious disease (ID) and it was recommended to treat the patient with amikacin, primaxin and tigecycline. His amikacin was held due to a suspected allergy. His IV antibiotics continued.
A cardiology consultation recommended a repeat echocardiogram, continue Lasix. The chest pain was not suggestive of acute coronary syndrome (ACS), but due to recent surgery. It was not clear if the LE edema was due to an allergic reaction. The radial artery fistula was most likely due to recent catheterization.
Cardiology follow suggested to change the Lasix to oral, and noted that the leg edema resolved. Cardiology recommended for the patient to stay for one more day, but if the patient went home, to follow with his cardiologist. The patient left against medical advice (AMA).
At issue is the medical necessity of an inpatient level of care.

The requested health service/treatment of inpatient stay was not medically necessary for this patient.
The patient presented with LE edema and a possible allergic reaction to amikacin. The patient had undergone surgery at an outside institution and presented to this hospital with LE edema and pruritis with the concern for an allergic reaction versus edema due to heart failure.
The patient still had chest heaviness and dyspnea, but they were residual symptoms after heart surgery, according to the consulting cardiologist. Diuresis was recommended, but the IV Lasix was changed to oral Lasix. His BNP was elevated, but close to his baseline.
His vascular studies, venous and arterial, were negative for acute disease. The patient had an arteriovenous fistula on his wrist after cardiac catheterization, however, that was not acute, was asymptomatic and could have been handled as outpatient. The patient's vital signs were normal, he was not febrile and was not in distress.
His echocardiogram revealed pulmonary hypertension, but it was not acute. The patient's condition and management did not require acute inpatient admission. Care could have been provided at a lower level of care.