Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute congestive heart failure (CHF)

Treatment: Inpatient stay

The insurer has denied coverage for inpatient stay.

The denial is upheld. 

The patient was a male with history of diabetes mellitus (DM), hypertension (HTN), hyperlipidemia (HLD), coronary artery disease (CAD) status post myocardial infarction (MI), sarcoidosis, and chronic kidney disease (CKD) who presented to the Emergency Department (ED) with complaints of shortness of breath and cough for the past week. The patient had received some treatment as outpatient with steroids and antibiotics but had not gotten significant relief. The patient's vital signs at presentation were: temperature of 98.5, heart rate of 74, respiratory rate of 20, and blood pressure of 125/67. The patient's pulse oximetry was 95% on room air. On exam, the patient was in no acute distress (NAD); the patient had some rales noted in the lungs and pedal edema. The patient was awake and alert. The patient's white blood cell (WBC) count was 14.8K, which was likely attributed to the patient's recent use of steroid therapy. The patient's electrolytes were within normal limits. The patient's BUN/Creatinine was 32/2.1, BNP was 299 and Troponin was negative. The patient's electrocardiogram (EKG) showed no acute ischemic changes.

The patient's chest x-ray revealed some patchy infiltrate with premature ventricular contractions (PVC). The patient's influenza screen was negative. The patient was treated with intravenous (IV) Lasix for diuresis, and was also treated with bronchodilators and other maintenance cardiac medications. The patient was admitted to Telemetry and serial EKG/Troponin testing was done. The patient had elevated D-dimer, so a V/Q scan and deep vein thrombosis (DVT) study were ordered. The patient's V/Q scan was not suggestive of pulmonary embolism (PE), and the patient's DVT study was negative. The patient's renal sonogram revealed parenchymal disease consistent with this patient's diagnosis of CKD but no hydronephrosis.

Based on the review of the literature, this patient did not need acute inpatient hospitalization. The patient had responded to intravenous (IV) Lasix with brisk diuresis. This patient could have been placed on Observation status while diagnostic testing and treatment were initiated. This patient had started responding to Lasix while in the Emergency Department (ED). This patient's main reason for admission was fluid overload due to acute congestive heart failure (CHF). This patient's diagnostic testing was negative for pulmonary embolism (PE) and deep venous thrombosis (DVT). The patient's cardiac workup was negative for myocardial infarction (MI). This patient could have been discharged once MI and PE were ruled out. The patient remained afebrile, hemodynamically stable and was able to be discharged the next day on oral medications. The patient was tolerating oral intake at the time of admission. The patient could have been discharged after a period of observation once serious conditions, such as MI and PE diagnoses were ruled out with testing. Thus, inpatient admission was not medically necessary for this patient.

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the acute inpatient stay should be upheld. The medical necessity is not substantiated.