Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System. 
Treatment: Inpatient Hospital. 

The insurer denied Inpatient Stay. 
The denial is upheld. 

The patient is a male with a past medical history significant for nonischemic cardiomyopathy with severely reduced ejection fraction, cardiac thrombosis being anticoagulated with Eliquis, status post-automatic implantable cardioverter defibrillator (AICD), and hyperlipidemia who presented to the hospital with complaints of shortness of breath. It was reported that the patient had multiple runs of ventricular tachycardia in the emergency room (ER). However, there was no loss of consciousness or AICD firing.
When seen by the admitting physician the patient was diaphoretic and in severe respiratory distress. He was unable to finish a full sentence. The patient was placed on bi-level positive airway pressure (BiPAP) and started on Amiodarone and nitroglycerin drips. In addition, while in the emergency department, the patient received treatment with Lasix, and as a result, his shortness of breath improved. Subsequently, the nitroglycerin drip was discontinued. The electrocardiogram (EKG) performed in the emergency department demonstrated sinus rhythm with first-degree atrioventricular (AV) block and premature ventricular contraction (PVC)s. On the physical exam, the patient was afebrile. His heart rate was 79 beats per minute (bpm), respiratory rate was 25 breaths/minute, blood pressure was 96/62, and oxygen saturation was 100% on room air. The patient was in respiratory distress, and he had rales bilaterally at the basis. The abdomen was soft, non-tender, and non-distended. The patient was awake and alert. The rest of the physical exam was clinically unremarkable. 
The arterial blood gas (ABG) revealed a potential hydrogen (pH) of 7.29, partial pressure of carbon dioxide (pCO2) was 51, partial pressure of oxygen (pO2) was 434, bicarbonate was 24.5, and oxygen saturation of 99.8%. The chest x-ray demonstrated central pulmonary vascular and interstitial prominence suggestive of congestive changes.
The patient was admitted to the hospital with acute systolic congestive heart failure (CHF). The patient was treated with BiPAP, Lasix, and Coreg. He was continued on Eliquis. It was suspected that the patient's elevated troponin was likely related to demand ischemia. Since the patient's clinical condition improved, he was transitioned to outpatient care. 

At issue is the medical necessity of the Inpatient Stay. 

The health plan's determination of medical necessity is upheld in whole. 

The requested health service/treatment of Inpatient Stay was not medically necessary for this patient. 
The hospital stay was not medically necessary for this patient at the acute inpatient level of care.  Overall, the patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. The review of the medical records showed no evidence that the patient had hemodynamic instability, acute kidney injury, or severe electrolyte abnormalities requiring inpatient care. It was reported that the patient had runs of ventricular tachycardia, however, in the hospital, the patient remained in normal sinus rhythm. There was no evidence that CHF was associated with pneumonia or pulmonary embolism. There was no evidence that the patient had severe pulmonary edema. There was no evidence of massive skin edema, intractable pulmonary edema, persistent tachypnea, altered mental status, or acute peripheral ischemia. The patient did not require pulmonary artery catheter monitoring. He did not need any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. Overall, the patient's clinical condition improved quickly, and the patient remained in stable clinical condition throughout the hospitalization. 

Therefore, the Inpatient Stay was not medically necessary.