Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Cardiac/circulatory Problems
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has overturned in whole the health plan's determination.

The patient presented to the emergency department complaining of dyspnea, cough, and intermittent left-sided chest pain. His medical history was remarkable for chronic hepatitis C, metastatic hepatocellular carcinoma and cholangiocarcinoma being treated with chemotherapy, diabetes, hypertension, coronary artery disease, heart failure with reduced ejection fraction, cardiac arrest, chronic obstructive pulmonary disease (COPD) and depression. His blood pressure was 96/64 millimeters of mercury (mmHg) with a heart rate of 92 beats/minute. His respiratory rate was 20/minute with a room air oxygen saturation of 93%. This increased to 95% with 3 liters/minute of supplemental oxygen. He was afebrile. On physical exam his lungs were clear with coarse breath sounds. An electrocardiogram showed sinus tachycardia at 101 beats/minute without acute changes. Chest X-ray showed no acute pathology. Chest computed tomography (CT) scan showed clear lungs and mediastinal adenopathy. The patient's serum troponin level was normal and remained normal when re-measured. His serum creatinine level was 1.3 milligrams per deciliter (mg/dl) with a glomerular filtration rate (GFR) of 56 (baseline GFR 75). He was treated with aspirin and admitted to the hospital for management of decompensated heart failure and COPD exacerbation, and possible acute coronary syndrome and/or pneumonitis. Prednisone, furosemide, and antibiotics were prescribed. The patient's Entresto was held due to his acute kidney injury. An echocardiogram showed a left ventricular ejection fraction of 35-40% with regional wall motion abnormalities. The patient reported an improvement in his symptoms. Myocardial perfusion imaging showed a large fixed anterior, apical and anteroseptal perfusion defect with minimal reversibility. His serum creatinine was 1.1 mg/dl with a GFR of 67. On the next day the patient's GFR was 85. He was discharged. 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 dyspnea and chest pain that were attributed to decompensated heart failure and COPD exacerbation. Acute coronary syndrome and pneumonitis were also considered as diagnoses but were ruled out.
Regarding the patient's acute decompensated heart failure (ADHF): This patient had several high-risk features including systolic blood pressure less than 100 mmHg, active malignancy, and acute kidney injury with a significant decrease in his glomerular filtration rate. He also had COPD exacerbation; the co-existence of COPD in patients hospitalized for ADHF has been shown to be an independent predictor of major adverse events. Based on his Emergency Heart Failure Mortality Risk Grade score, he was at intermediate risk for 7-day mortality; inpatient admission is recommended in this situation. In addition to ADHF the patient was diagnosed with COPD exacerbation. While many patients with COPD exacerbation can be treated on an outpatient basis, current guidelines recommend inpatient care for patients with unstable comorbidities, such as the decompensated heart failure in this patient. Given this patient's risk for major adverse events, an inpatient level of care with the ability to intervene emergently if needed, was medically necessary.