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 of heart failure, cerebrovascular accident (CVA) without residual deficits, pulmonary embolism, and nicotine dependence. He presented to the Emergency Department (ED) with a 2-week history of exertional shortness of breath, orthopnea, paroxysmal nocturnal dyspnea (PND), and a cough. He also reported that his legs felt weak. He had been off his diuretics for the past two weeks. He also reported a loss of sense of taste and smell which concerned him for coronavirus 2019 (COVID-19) infection. On initial exam he was "pleasant, cooperative male lying comfortably on stretcher. Breathing comfortably on room air. Speech clear and fluent. Answers questions appropriately. Follows commands appropriately." Given concern for heart failure exacerbation, he was given one dose of intravenous (IV) Lasix with significant improvement of his breathing. While in the ED, there was concern for an episode of delirium with the provider note stating that "the patient does seem somewhat tired, has difficulty keeping his eyes open, and sometimes falls asleep during my examination. However, he is able to answer questions appropriately. He is not having any chest pain, difficulty breathing or any new complaints. His pulse oximeter variably reads anywhere between 80% and 98% on room air, so I had nursing staff place him on 2 liters (L) by nasal cannula as a precaution." The patient had a few more episodes of delirium/agitation requiring Ativan. On the day of discharge, he was saturating well on room air and was alert and oriented. He was discharged home on oral Lasix with outpatient follow up with his primary care physician (or provider) (PCP) and cardiologist.
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. 
Based on the provided documentation, there is insufficient clinical data to support that an inpatient level of care was medically necessary for this patient. This is a patient with a history of heart failure, CVA, and pulmonary embolism who presented with progressively worsening shortness of breath in the setting of non-compliance with his diuretics. His presentation was consistent with heart failure exacerbation, and he responded well to a dose of intravenous (IV) Lasix. He was hemodynamically stable, was initially breathing well on room air and there was no evidence of organ damage or severe electrolyte abnormalities on his laboratory work up. There were intermittent episodes of agitation/delirium during which he had intermittent episodes of hypoxia. However, this was in the absence of focal neurologic deficits or toxic/metabolic/infectious causes of encephalopathy. The episodes of hypoxia were intermittent and non-sustained. On the day of discharge, he was reportedly alert and oriented and was saturating well on room air. As a result, admission to an inpatient level of care was not medically necessary. 
Therefore, the requested health service/treatment of Inpatient Stay was not medically necessary.