Diagnosis: Congestive heart failure.
Treatment: Inpatient admission.

The insurer denied coverage for an inpatient admission.

The denial is overturned.

This patient has a history of congestive heart failure (CHF), hypertension, and substance abuse. The patient was on Methadone and presented to the hospital with complaints of abdominal pain for 3 weeks and chest pain and shortness of breath (SOB) for 1 month. The patient also complained of some burning micturition. The patient's home medications included Lasix and Entresto. The ejection fraction was 30 percent (%). He presented with a CHF (congestive heart failure) exacerbation and was noted to have elevated jugular venous distention (JVD). The lung exam revealed crackles and pedal edema was also noted.

His B-type natriuretic peptide (BNP) was 1812 and then 3700. His Troponin was 0.06. The Blood urea nitrogen (BUN) and Creatinine (Cr) were elevated at admission. An acute kidney injury (AKI) was noted as Cr was 1.4 from a baseline of 0.9. A chest x-ray revealed a pulmonary edema pattern.

The patient was admitted for decompensated CHF. He was started on intravenous (IV) Lasix 40 milligrams (mg) twice daily (BID), Entresto was held due to the AKI. Subsequently Lasix was increased to 80 mg IV BID. The patient was also treated with Spironolactone. Acute Coronary Syndrome was ruled out. The patient's Cr increased to 1.8 and fluids were adjusted. This patient was also treated with Bactrim for a possible urinary tract infection (UTI).

This patient had presented with acute decompensated CHF. He needed acute hospitalization for treatment with IV Lasix. His intake and output were monitored strictly. In addition, other medications and fluids had to be adjusted due to his AKI which had become worse after hospitalization. Admission and length of stay was appropriate. The patient decided to sign out against medical advice (AMA).

The health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.

The insurer's denial of coverage for the inpatient hospital admission is overturned. Medical necessity is substantiated.