Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Decompensated Heart Failure
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a male patient who presented to the emergency department (ED) complaining of worsening exertional dyspnea. His medical history was remarkable for hypertension and heart failure with a reduced ejection fraction (20-25 percent [%]).His physical exam was remarkable for tachypnea, use of accessory muscles of respiration, jugular venous distension and expiratory wheezing. An electrocardiogram showed atrial flutter with a ventricular rate of 115 beats/minute. His serum troponin level was .042 nanograms/milliliter (ng/ml). His serum creatinine level was 1.62 milligrams per deciliter (mg/dl) (baseline 1.08 mg/dl). His N terminal pro brain (or B-type) natriuretic peptide (BNP) level was 9370 picograms per milliliter (pg/ml). A chest x-ray showed cardiomegaly. Chest computed tomography (CT) angiography showed bilateral airspace opacities. The patient was treated with intravenous furosemide and metoprolol.  Twice daily intravenous furosemide was prescribed. The patient's dyspnea gradually improved with diuresis. Guideline-directed medical therapy (GDMT) for heart failure was initiated. Myocardial perfusion imaging suggested mild stress induced ischemia in left ventricular apex and interventricular septum. Cardiac catheterization was performed and showed normal coronary arteries. The patient's serum creatinine level was 1.3 mg/dl (milligrams/ deciliter). The furosemide was held, and intravenous fluids were administered. Dapagliflozin was prescribed. Transesophageal echocardiography followed by electrical cardioversion if no intracardiac thrombus was identified was recommended; however, the patient declined. Implantation of an implantable cardioverter defibrillator or a LifeVest wearable cardioverter defibrillator was also recommended but was also declined. The patient was discharged. The medical necessity for an inpatient admission is at issue.

Based on the documentation provided, an inpatient level of care was medically necessary.
This patient presented with decompensated heart failure. He had an acute kidney injury with a 38% (percent) decrease in his estimated glomerular filtration rate compared to this baseline. Acute kidney injury in patients hospitalized with decompensated heart failure is associated with significantly higher in-hospital mortality, longer duration of hospital stay, increased risk for readmission and increased risk of in-hospital complications including cardiac arrest and cardiogenic shock. Moreover, his N terminal proBNP (pro brain (or B-type) natriuretic peptide) level of 9370 pg/ml (picograms/ milliliter) was an additional high-risk feature. In patients with decompensated heart failure, levels greater than 5000 pg/ml have been associated with substantially increased short- and long-term mortality. Based on this patient's Ottawa Heart Failure Risk Grade score, his risk for serious adverse events was high at 39.8% (percent). He required careful and continuous monitoring with the ability to intervene emergently, if needed. This warranted an inpatient admission.