Diagnosis: Shortness of Breath and Chest Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a female. She was hospitalized for shortness of breath and chest pain x 1 week. The clinical impression was new-onset heart failure. Her PMH (past medical history) is pertinent for HTN (hypertension), atrial fibrillation, DM2 (diabetes mellitus) and MG (myasthenia gravis).

The patient's vital signs revealed the following: BP (blood pressure) elevated to 177/112, HR (heart rate) 106, RR (respiration rate) 18 and O2 (oxygen) saturation 98% on RA (room air). Respirations were even and non-labored. Lungs were diminished at the bases. Pro-BNP (prohormone brain natriuretic peptide) was elevated to 4780. Her treatment included IV (intravenous) Lasix 40 mg (milligrams) x 1 dose and BiPAP (bi-level positive airway pressure). Chest CTA (Computed Tomographic Angiography) was negative for PE (pulmonary embolism) and showed a left pleural effusion. She felt improved and left AMA (against medical advice).

This is an appeal of the denied claim the requested Acute Inpatient Hospital Stay was medically necessary for this patient.

No, the Inpatient admission was not medically necessary.
Based on the peer reviewed medical literature and this reviewer's expert medical opinion, the documentation submitted for review does 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), Hypertension (ORG: M-197) and Cardiology GRG, the inpatient admission was not medically necessary. The severity of this patient's illness did not meet the intensity of service for inpatient hospital stay per the guidelines. 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. There was no clinical decline or inadequate response to treatment which required continuation of the hospital stay past the observation period. The care she received is routinely provided safely and effectively at a lower level of care. Therefore, the Inpatient admission was not medically necessary, based on the submitted information and the current published evidence-based guidelines.

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