Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness Of Breath.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male. He was hospitalized for acute on chronic systolic heart failure, in the setting of medication noncompliance. He presented to the ED (emergency department) for evaluation of worsening DOE (dyspnea on exertion) with minimal effort and three-pillow orthopnea. His PMH (past medical history) is pertinent for known cardiomyopathy with LVEF (left ventricle ejection fraction) 10-20% (percent), HTN (hypertension), HLP (hyperlipidemia), COPD (chronic obstructive pulmonary disease) and CKD (chronic kidney disease).

This is an appeal of the denied claim the requested Acute Inpatient Hospital Stay was medically necessary for this patient approved at the Observation level of care.

No, the proposed treatment is not "medically necessary".
Based on the peer reviewed medical literature and this reviewer's expert medical opinion, the documentation submitted for review do not establish the requested Acute Inpatient Hospital Stay was medically necessary for this patient. According to the MCG (Milliman Care Guidelines) Guidelines titled: Heart Failure (ORG: M-190), the inpatient admission was not medically necessary, because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay per the guideline. Criteria for inpatient stay are not met, including documentation of hemodynamic instability, respiratory distress, change in mental status, severe heart failure, cardiac arrhythmias of immediate concern, myocardial ischemia or myocardial infarction, positive troponin not explained by CKD (chronic kidney disease) and CHF (congestive heart failure), hypertension requiring inpatient hospitalization, CVA (cerebrovascular accident), pulmonary embolism (PE), aortic dissection, pneumonia, severe electrolyte abnormalities or any other medical condition or other medical instability or acute care needs for which emergency and observation care have failed or are not considered appropriate and that would require acute inpatient management. The care he received for mildly decompensated chronic LV (left ventricle) systolic HF (heart failure) from medication noncompliance is routinely provided safely and effectively at a lower level of care, such as at the hospital's Observation level of care. Therefore, the inpatient admission was not medically necessary, based on the submitted information and the current published medical literature and evidence-based standards.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.

The patient's vital signs were stable: BP (blood pressure) 107/72, HR (heart rate) 78, RR (respiration rate) 20 and O2 sat (oxygen saturation) 98%. He was in NAD (no acute distress), resting comfortably in a chair. His lungs were with scattered bibasilar rales. ICD (implantable cardioverter defibrillator) interrogation revealed normal function and no VT/VF (ventricular tachycardia/ventricular fibrillation). CXR (chest x-ray) showed CM (cardiomegaly), bibasilar opacities and small right pleural effusion. Serial troponins were 0.123, 0.100 and 0.93.