Diagnosis: Heart Failure
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a morbidly obese male admitted with exacerbation of his congestive heart failure (CHF). The patient was estimated to be grossly fluid overloaded with at least 30 pounds of excess despite high dose oral diuretics at home. The recommendation was for intravenous (IV) diuresis of two liters per day. Co-morbidities included obesity, hypertension, atrial fibrillation, chronic renal failure (CRF), diabetes mellitus (DM), hyperlipidemia (HLP), obstructive sleep apnea (OSA), and recent knee surgery. Chest x-ray (CXR) showed pulmonary vascular congestion and examination revealed bi-ventricular failure. Ejection fraction (EF) was reduced at 40%. Diabetes was poorly controlled. The patient was started on intravenous diuresis with Lasix 80 milligrams (mg) daily. Advanced heart failure therapy was initiated.

Yes, the proposed inpatient admission was medically necessary.

This is an extremely complex patient with congestive heart failure (CHF) who failed outpatient medical therapy. High dose intravenous diuresis and addition of advanced congestive heart failure therapy were initiated. With the presence of multiple co-morbidities, including renal failure, uncontrolled diabetes and morbid obesity, the patient was extremely difficult to manage. He did require daily labs to monitor his renal failure (risk of worsening was high). He had failed outpatient therapy with high doses of oral diuretics. His care and treatment did require inpatient level of care.

The patient's actual treatment met standard of care and required inpatient admission to achieve.