Diagnosis: Congestive heart failure.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is overturned.

This is an adult male who presented to the hospital complaining of shortness of breath and weight gain for several days duration. Past medical history was significant for heart failure with reduced ejection fraction, coronary artery disease, diabetes mellitus, mechanical aortic valve replacement, and subcutaneous implantable cardiac defibrillator. On physical examination blood pressure 156/80 and pulse was 60. Mechanical heart sounds were noted along with minimal pedal edema. 12 lead electrocardiogram (EKG) demonstrated sinus rhythm at 60 without acute ischemic changes. Serum blood testing revealed elevated troponin at 0.03 and B-type natriuretic peptide (BNP) 1210. The patient was treated with intravenous furosemide and admitted to the hospital for treatment with guideline directed medical therapy.

This patient presented with complaints of dyspnea and weight gain. Upon presentation, physical exam and laboratory testing confirmed fluid overload due to systolic congestive heart failure. He required treatment with intravenous diuretic therapy and was ultimately discharged on oral guideline directed medical therapy. Failure to admit and treat this patient would have resulted in excess morbidity or even mortality. Patients with chronic congestive heart failure have a high risk of adverse outcomes warranting a higher level of care. (Reference 1) In one study, patients presenting with congestive heart failure and an elevated BNP level were found to have an increased morbidity and mortality in the subsequent 90 days. (Reference 2) In conclusion this patient had decompensated congestive heart failure and an elevated BNP level. Inpatient hospital admission was medically necessary.

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 full hospital admission is substantiated.