Diagnosis: Decompensated CHF with ongoing cardiac ischemia.

Treatment: Admission inpatient to Telemetry

The insurer denied the coverage. The denial was reversed.

This is a female patient with history of Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), Hypertension (HTN), Wolff-Parkinson-White (WPW) syndrome, Long QT syndrome, Asthma and Polysubstance Abuse, who presented to the Emergency Department (ED) with increasing lower extremity swelling for about two weeks and facial swelling for one day. The patient had been actively using drugs. She last used Heroin two days prior. The patient denied chest pain but complained of some shortness of breath and decreased exercise tolerance. Vital signs at presentation were Temperature (T) 97.7 F, Respiratory Rate (RR) 20, Heart Rate (HR) 88, Blood Pressure and (BP) 150/100 mm Hg. Oxygen (O2) saturations were 93%. The patient had some elevated jugular venous distention. Lungs were clear. CVS S1 S2 +. Edema, feet +. The patient had a CT Chest which revealed Atelectasis/Infiltrate on the left side, and right sided Atelectasis. Due to the possibility of Pneumonia, Doxycycline was started. The patient was admitted to Telemetry with diagnosis of decompensated CHF with ongoing cardiac ischemia.

This patent had a complicated presentation with decompensated heart failure (HF) with possible ongoing ischemia in the setting of multiple other co-morbidities. The patient was actively using Heroin and Cocaine. Possible Pneumonia was present for which the patient received intravenous (IV) antibiotics. In addition the patient developed some worsening of renal function due to diuresis and this needed close monitoring due to the patient's underlying congestive heart failure (CHF).The patient lacked mental capacity so was deemed incompetent by Psychiatry and needed 1:1.

This patient was not stable to be placed on Observation or discharged from the Emergency Department (ED). She needed admission for treatment and close monitoring of her clinical status. Myocardial Infarction (MI) needed to be ruled out and Cardiac arrhythmia was a possibility given her WPW and Long QT Syndrome. The carrier's denial of coverage for the inpatient is reversed. The medical necessity is substantiated.