Diagnosis: Shortness of breath/leg edema.
Treatment: Inpatient stay.

The insurer denied the inpatient stay. The health plan's determination is upheld.

This case involves a man with congestive heart failure and hypertension, substance abuse, history of pulmonary embolism, left ventricular (LV) thrombus, and chronic kidney disease (CKD) who presented to the emergency department (ED) with shortness of breath and lower extremity edema. The patient has heroin and cocaine dependence and used the substances 1 day before arrival. The patient has had nonischemic cardiomyopathy for the past 6 years, with a fairly low ejection fraction of 20%, moderate to severe tricuspid regurgitation, and pulmonary hypertension 3 months before this presentation. The patient had a normal cardiac catheterization study.
On arrival in the ED, the patient reported noncompliance with medical therapy, and reported intermittent chest pain without radiation.

The inpatient hospital stay is not medically necessary for this patient. The patient has a known history of nonischemic cardiomyopathy, with heart catheterization performed just three months before this presentation, showing no evidence of coronary stenosis. He presented to the hospital with volume overload due to noncompliance with guideline-directed medical therapy for heart failure treatment. After initiating intravenous (IV) diuretics by the medical and cardiac team, the patient's symptoms rapidly improved. Both the chest x-ray and computed tomography angiography (CTA) of the chest showed mild pulmonary edema, and there is no documentation to support severe hypoxic respiratory failure. The leg edema is described as nearly resolved by 24 hours into the hospital stay. The diuretic therapy was converted to oral within 24 hours. There were no major electrolyte derangements. The medical team describes underlying chronic kidney disease stage III from a renal standpoint, which estimates the glomerular filtration rate (GFR) between 30 and 60. The patient's GFR was 58 at the time of admission and around 60 at discharge. Therefore, there is no evidence of severely decompensated renal function contributing to the volume overload.