Diagnosis: Difficulty breathing and lower extremity edema
Treatment: Inpatient hospital admission
The proposed treatment, inpatient admission, was medically necessary.
The patient presented with an acute exacerbation of CHF, with recurrent atrial fibrillation with rapid ventricular response (RVR), signs of end-organ hypoperfusion - elevated lactate level. Also his WBC count was severely elevated, raising a suspicion of an acute infectious or inflammatory process. Given the presentation, uncontrolled atrial fibrillation, as well as acute CHF exacerbation, and possible infectious process, he would not be an appropriate candidate for an ED observation unit, and it would be consistent with the current standard of care that this patient be managed in an inpatient setting, and therefore the requested inpatient admission was medically necessary in this clinical setting.