Diagnosis: Acute Decompensated Systolic Congestive Heart Failure (CHF)

Treatment: hospital admission

The insurer denied coverage for hospital admission.

The denial is upheld.

This is the case of an adult male patient with a past medical history notable for congestive heart failure , left ventricular systolic dysfunction with ejection fraction (EF) 20% (percent), mitral valve replacement, and atrial fibrillation. He presented to the hospital with a 3-day history of worsening shortness of breath and orthopnea. He reported that his symptoms were similar to those he had experienced prior to his mitral valve surgery. The patient was found to have respiratory distress and hypoxia requiring oxygen supplementation. The troponin levels were borderline, but not diagnostically positive for myocardial ischemia or infarction. Blood pressure was 160/103 with a heart rate between 88-120. The rhythm was atrial fibrillation. His oxygen saturation in the Emergency Room (ER) was 96% on room air. The patient was admitted with acute decompensated systolic CHF. He was started on intravenous (IV) Lasix. An echocardiogram was performed, showing EF of 25%, mean mitral valve gradient of 5 millimeters of mercury (mmHg), and at least moderate mitral regurgitation. He was transitioned to oral Lasix 40 milligrams (mg). He was also started on Entresto and spironolactone. Amlodipine was discontinued. The patient was cleared for discharge home with outpatient follow-up appointments.

The patient was admitted with symptoms of CHF. His care could have been rendered under observational status. There was clinical CHF supporting necessity of observational care, while inpatient admission status was not met due to lack of severity of disease or comorbidities. There was no evidence of myocardial ischemia, hemodynamic instability, electrolyte abnormalities, hypoxemia, or other indications to substantiate medical necessity for acute inpatient admission status for the dates under review. Per Milliman Care Guidelines (MCG) 24th Edition Guideline Heart Failure: Observation Care the patient's care could have been provided under observational level of care.

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

Inpatient admission was not medically necessary for this patient.

The insurer's denial of coverage for the hospital admission is upheld. Medical necessity not substantiated.