Diagnosis: Shortness of Breath

Treatment inpatient level of care

The insurer denied coverage for inpatient level of care

The denial is upheld

The patient is a gentleman with a history of hypertension, diabetes mellitus systolic congestive heart failure and atrial fibrillation that presented to the hospital complaining of worsening dyspnea over a three-day period after running out of medication. In addition, he reported lightheadedness that lasted for 15 minutes before resolving spontaneously. Upon arrival, Blood Pressure was 152/88 and pulse was 110. Electrocardiogram (ECG) revealed atrial fibrillation (AF) with ventricular rates of 90-100 without acute ST-T (intervals on ECG) wave changes and poor precordial R (interval on ECG) wave progression. Echocardiogram revealed severely dilated atria and a mildly reduced left ventricular ejection fraction (LVEF) of 50% (percent). On physical exam the patient had 2 plus pitting edema up to the mid-calf and wheezing over the right lung field. Chest x-ray revealed mild pulmonary vascular congestion and brain natiuretic peptide (BNP)was elevated at 575. Serum blood testing revealed a blood urea nitrogen (BUN) of 25 and a creatinine (CR) 1.5 mg/dl (milligram per deciliter). Of note, the patient was discharged from the hospital several weeks prior to presentation and he noted significant weight loss while on furosemide therapy. The patient was admitted to the hospital and started on oral lasix and ultimately discharged.

The health plan acted reasonably and in the best interest of the patient. This patient presented with dyspnea and a mildly elevated pro BNP level. He also reported an episode of lightheadedness but had no significant hypotension, tachycardia or bradycardia to explain such symptoms. Dyspnea was temporally related to medical non-compliance. Following treatment with guideline directed medical therapy (furosemide) symptoms resolved and the patient was continued on his outpatient regimen (Reference 1).

Masri et al. compared patient outcomes following treatment of acute congestive heart failure in observation and inpatient settings and demonstrated no difference in mortality between the two groups. (Reference 2).

This patient responded to treatment with his previously prescribed oral medications. In conclusion, this patient could have been treated at a lower level of care and did not require inpatient admission.

The health care plan did act reasonably, with sound clinical judgment, and in the best interest of the patient. An inpatient admission was not medically necessary.

The insurer's denial of coverage for the inpatient level of care is upheld. Medical necessity is not substantiated.