Diagnosis: Heart Failure, Sepsis.
Treatment: Inpatient admission.
The insurer is denied coverage for inpatient admission.
The denial is overturned.

This is a male patient with history of metastatic lung cancer with metastases to the brain, atrial fibrillation on Eliquis, congestive heart failure (CHF), and pulmonary hypertension (PHTN). The patient presented to the Emergency Department (ED) with shortness of breath (SOB)/dyspnea on exertion (DOE), palpitations, bilateral lower extremity swelling, and chills. The patient's vital signs on presentation were; temperature of 100.9F, heart rate (HR) of 156 ; irregular, respiratory rate (RR) of 31 and oxygen (O2) saturations in the 80's. On exam, the patient's lung revealed bilateral rales and bilateral lower extremity edema. Laboratory work up was performed that revealed a white blood cell (WBC) count to 16.3 K, BUN/Creatinine 30/0.9 and hemoglobin (Hb) 11.5, brain natriuretic peptide (BNP) 2046, troponin 0.49 and lactate was 3.5. The patient received intravenous (IV) metoprolol and Digioxin for heart rate control, intravenous (IV) Lasix and IV antibiotics. Oxygen was administered at 6L nasal cannula (NC). The patient was pan-cultured. A computed tomography (CT) angiogram was done that was negative for a pulmonary embolism (PE). The patient had progression of disease with worsening left lower lobe (LLL) mass and adenopathy. The patient's lungs had bilateral ground glass opacity and patchy bilateral opacities; thickening of interlobular septa and small right pleural effusion. The patient was admitted to the hospital with a differential diagnosis that included infectious etiology vs. drug reaction vs. lymphangitic spread. The patient was continued on beta blocker. The patient expired.

The patient was admitted for possible pneumonia and sepsis, decompensated heart failure (HF) and atrial fibrillation with rapid ventricular response (RVR). The patient remained hypoxic, tachycardic, and had atrial fibrillation with RVR. The patient's lactate was elevated, and the patient had leukocytosis and elevated troponin. This patient remained in hypoxic respiratory failure requiring supplemental oxygen (O2) 6 Liters nasal cannula (NC). The patient continued to be tachycardic requiring beta blockers. The patient became hypotensive after treatment. The patient was not stable to be placed under observation. After admission to the floor, the patient's condition further deteriorated. The rapid response team (RRT) was called. The patient went into cardiac arrest. Despite advanced cardiac life support (ACLS), the patient could not be revived. The patient was critically ill with sepsis/pneumonia/atrial fibrillation with rapid ventricular response and decompensated heart failure (HF). Literature review supports that inpatient admission was medically necessary for this patient.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient admission should be overturned. The medical necessity is substantiated.