Diagnosis: Congestive heart failure.
Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is overturned.

Asked to review the case of an adult that presented to the first hospital with complaints of dyspnea, cough, orthopnea and pedal edema. Work up revealed influenza B infection and bilateral pulmonary infiltrates on computed tomography (CT) scan. Her hospital course was complicated by persistent dyspnea and echocardiography revealed significant mitral and aortic valvular disease as well as congestive heart failure. She was transferred to another hospital for work up and treatment of congestive heart failure. Upon arrival vital signs were stable. Physical examination was significant for a 3/6 systolic murmur. Serum blood testing revealed hypokalemia with a potassium of 3.2 and an elevated B type natriuretic peptide 1692. Transesophageal echocardiogram revealed a left ventricular ejection fraction of 45-50%, a bicuspid aortic valve with severe aortic stenosis and severe aortic regurgitation. Cardiac catheterization was ordered in preparation for aortic valve replacement surgery. Results confirmed severe aortic stenosis and revealed normal coronary arteries. The patient was treated medically with beta blocker therapy and diuretics and discharged with plans for eventual aortic valve surgery.

This patient presented with symptoms of heart failure complicating a recent viral infection and required extensive work up for bicuspid aortic valve with severe stenosis and regurgitation. Recent American Heart Association/American College of Cardiology guidelines recommend a multidisciplinary approach when treating patients with valvular heart disease and congestive heart failure in order to prevent worsening of heart failure and adverse outcomes. (Reference 1) Given this patient's presentation with acute and difficult to manage congestive heart failure, it was appropriate that such a multidisciplinary approach occur in an inpatient setting. Masri et al. compared patient outcomes following treatment of acute congestive heart failure in observation and inpatient settings and demonstrated a significant readmission rate in patients managed in observation. (Reference 2) Patients in this study that required cardiac catheterization and detailed diagnostic work up tended to be managed utilizing an inpatient hospital strategy. This patient presented with severe aortic stenosis and regurgitation and congestive heart failure that required inpatient treatment and work up.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for the inpatient admission is substantiated.