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

The patient is a male. He was hospitalized at an out of network facility for newly diagnosed HFrEF (heart failure with reduced ejection fraction) of 15-20%. It was suspected that this might be from viral myocarditis. His PMH (past medical history) includes Hypertension, morbid obesity, CKD (chronic kidney disease) and hyperlipidemia.

The patient's exam was remarkable for generalized edema with dyspnea on exertion, RR (respiration rate) of 18, diminished breath sounds and initial blood pressure reading of 129/65. O2 (oxygen) saturation was 94% on RA (room air). Chest x-ray reported stable cardiomegaly, slight increase in hazy opacities involving the mid to lower lung fields and increased blunting of the costophrenic sulci, right greater than left indicating worsening pleural effusions.

Treatment included IV (intravenous) bumetanide and losartan and hydralazine dosages were increased. No tracheal deviation or mediastinal widening. The visual structures are intact. Coronary CTA (Computed Tomographic Angiography) done was negative.

Coverage for the inpatient admission was denied by the health plan as not medically necessary, as the patient was deemed stable to transfer from the ED (emergency department) to an in network facility for further care. The denial is being appealed.

No, the Inpatient admission was not medically necessary.
Based on the peer reviewed medical literature, the documentation submitted for review do not establish the requested Acute Inpatient Hospital Stay was medically necessary for this patient. According to the MCG (Milliman Care Guidelines) Guidelines titled: Heart Failure (ORG: M-190), the inpatient admission was not medically necessary, because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay per the guideline. Criteria for inpatient stay are not met, including documentation of hemodynamic instability, respiratory distress, change in mental status, severe heart failure, cardiac arrhythmias of immediate concern, myocardial ischemia or myocardial infarction, positive troponin not explained by CKD (chronic kidney disease) and CHF (congestive heart failure) , hypertension requiring inpatient hospitalization, CVA (cerebrovascular accident), pulmonary embolism, aortic dissection, pneumonia, severe electrolyte abnormalities or any other medical condition or other medical instability or acute care needs for which emergency and observation care have failed or are not considered appropriate and that would require acute inpatient management. The care he received for an uncomplicated, acutely decompensated chronic LV (left ventricle) systolic HF (heart failure) is routinely provided safely and effectively at a lower level of care. The Inpatient admission was not medically necessary.

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