Diagnosis: Heart Disease.
Treatment: Inpatient admission.

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

The patient is a male. At the time of admission to the hospital, he had a past medical history significant for congenital heart block, status post (s/p) bi-ventricular pacemaker, non-ischemic cardiomyopathy with severely reduced ejection fraction (EF), and prior COVID infection. The patient presented due to congestive heart failure (CHF) exacerbation with worsening dyspnea on exertion, fatigue, and shortness of breath over several weeks. The patient was evaluated in the outpatient clinic and referred to the emergency department (ER).

The patient was given intravenous (IV) Lasix. The patient was hemodynamically stable. His blood pressure was normal and oxygen saturation was 99%. Labs revealed creatinine of 1.39 and brain natriuretic peptide (BNP) was elevated at 541. Electrocardiogram (ECG) revealed normal sinus rhythm with ventricular pacing. Chest x-ray revealed resolution of pulmonary edema. He was admitted for congestive heart failure (CHF) exacerbation management.

The next day, the patient underwent a right heart catheterization, which revealed normal pulmonary pressures. His orthostatic vitals were negative. A cardiopulmonary stress test was performed, revealing decrease exertional capacity. The patient was discharged home on medical therapy for congestive heart failure (CHF) with a plan for outpatient follow-up.

No, the proposed inpatient admission was not medically necessary.

This is a patient with known severe non-ischemic cardiomyopathy and congestive heart failure (CHF). He presented with worsening congestive heart failure (CHF) symptoms over several weeks. He was hemodynamically stable. He had normal oxygen saturation. He responded well to Lasix. Chest x-ray revealed resolution of pulmonary edema. Right heart catheterization revealed normal pulmonary pressures. 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.