Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dyspnea, Heart failure 
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient presented to the emergency department (ED) via Emergency Medical Services (EMS) complaining of four to five days of dyspnea. His medical history was remarkable for nonischemic cardiomyopathy and heart failure with a left ventricular ejection fraction of 21-25%. He was listed and waiting for heart transplantation. He admitted to taking extra doses of his prescribed torsemide at home because he was concerned about volume overload. In the ED, his blood pressure was 120/67 millimeters of mercury (mmHg) with a heart rate of 80 beats/minute. His room air oxygen saturation was 100%. His chest was clear and he had no peripheral edema. A chest x-ray showed no acute pathology. His brain (or B-type) natriuretic peptide (BNP) level was within the normal range at 29 picograms per milliliter (pg/ml). His serum sodium level was 133 millimoles per liter (mMol/L); his lactate level was 2.2 mMol/L. His serum creatinine level was 1.8 milligrams per deciliter (mg/dl) (baseline level 1.1 mg/dl). An electrocardiogram showed a ventricular paced rhythm.
The patient was admitted to the hospital for evaluation of acute kidney injury and dyspnea. His diuretics were held due to his acute kidney injury. He denied dyspnea. His serum sodium level was 135 mMol/L; his creatinine level was 1.3 mg/dl. The patient was seen by the heart failure specialist who opined that he was euvolemic and that his acute kidney injury was caused by the extra torsemide doses. His creatinine level was 1.1 mg/dl. His dyspnea was attributed to anxiety. There was no change to his home medical regimen and no further testing was recommended. The patient was deemed medically stable for discharge. However, he reported chest tightness and an inability to speak without dyspnea and remained in the hospital. The medical record indicated that the patient was stable for discharge; he continued to complain of marked dyspnea and remained in the hospital. He was discharged. The medical necessity for an inpatient admission is under review.

Based on the documentation provided, an inpatient level of care was not medically necessary. This patient was admitted to the hospital with an acute kidney injury (AKI) that was attributed to taking an extra torsemide doses. He was not hyperkalemic and his venous potential hydrogen (pH), bicarbonate level and anion gap were within normal limits. His renal function rapidly improved with holding of the torsemide and oral hydration. No other treatment for his AKI was necessary.
While the patient complained of dyspnea, there was no objective evidence of decompensated heart failure. His arterial oxygen saturation was normal, his lungs were clear and he had no peripheral edema. A chest x-ray showed clear lung fields and his brain (or B-type) natriuretic peptide (BNP) level was well within normal limits. The heart failure specialist opined that he was euvolemic and his dyspnea was attributed to anxiety. No treatment for decompensated heart failure was deemed necessary. Thus, the patient's complaints of dyspnea did not warrant an inpatient admission.