Diagnosis: Trouble breathing / fluid in the lungs.
Treatment: Inpatient admission.

The insurer denied the inpatient admission. The denial is overturned.

Yes, the Inpatient admission is "medically necessary".

The patient is a male at the time of admission to the hospital, with a past medical history significant for HTN (hypertension), obesity, bariatric surgery, diabetes mellitus, who presented to the ER with new onset dyspnea, progressive lower extremity edema and left-sided chest pain. The patient was hypertensive to 187/110, and had tachypnea to 27/minute. ECG revealed no acute ischemic changes. The chest X-ray revealed left pleural effusion, bilateral vascular congestion and opacities, which may represent pneumonia or atelectasis.

The patient was admitted for management of hypertensive urgency and new onset CHF (congestive heart failure). He was treated with IV Lasix and antihypertensive therapy was intensified. His BP (blood pressure) remained elevated to 196/102 and the BP therapy was escalated with increase in hydralazine and metoprolol. Echocardiogram was obtained and the patient was found to have normal EF (ejection fraction) with evidence of diastolic dysfunction. He was diagnosed with diastolic CHF and was his BP was treated with multiple agents. He was discharged home with a plan for outpatient follow-up.

The patient presented with symptoms of acute CHF exacerbation. His blood pressure was severely elevated, despite the therapy in the ED and with signs of acute CHF decompensation; his presentation was consistent with hypertensive urgency. He was appropriately treated with IV diuresis. He required close monitoring of his CHF, BP and titration of antihypertensive medications. Given the presentation, uncontrolled hypertension, as well as acute decompensated CHF, 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.