Diagnosis: Congestive Heart Failure exacerbation
Treatment: Inpatient stay

The inpatient admission was not "medically necessary".

The patient is a female admitted to the hospital with a past medical history significant for HTN (hypertension), asthma, CAD (coronary artery disease), status post CABG (coronary artery bypass graft) in 2015, diabetes mellitus, obesity and CHF (congestive heart failure), who presented to the ER for complaints of dyspnea on exertion and leg edema for one and a half weeks duration. The patient was hemodynamically stable. ECG did not reveal acute ischemic changes. Cardiac enzymes were negative. The patient was admitted for management of CHF exacerbation. The patient was treated with IV Lasix and was subsequently switched to oral diuretic. Her symptoms improved with treatment, and the patient was discharged from the hospital with a plan for outpatient follow-up.

The patient presented for management of CHF exacerbation. The patient was hemodynamically stable, with adequate oxygen saturation. The diagnosis of an acute MI was ruled out by cardiac enzymes, which were negative. There was no evidence of acute myocardial infarction, ACS, malignant arrhythmia or hemodynamic instability. The patient improved with diuretics, and her symptoms responded to treatment. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission, and the care required could have been provided at a lower level of care.