CurrentCurativePolicy CHP-IP-2026-003

A003. Acute Heart Failure / Heart Failure Exacerbation

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This policy governs medical necessity for acute inpatient admission, observation or outpatient management, level-of-care assignment, continued stay, and discharge readiness for adults with new-onset acute heart failure or acute decompensation of chronic heart failure, including heart-failure-related cardiogenic shock. It applies to Curative commercial PPO and EPO members in fully insured, level-funded, and self-funded plans.

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CurrentCurativePolicy CHP-IP-2026-003

A003. Acute Heart Failure / Heart Failure Exacerbation

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Policy Summary

PayerCurative

PolicyA003. Acute Heart Failure / Heart Failure Exacerbation

Policy CodePolicy N/A

Change TypeNo material change

Effective DateNovember 5, 2026

Next Review DateN/A

Key ActionDocument vital signs, oxygen requirement, and examination findings of congestion or hypoperfusion.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Adults 18+Applicable population

3-4 daysExpected length of stay

24 hoursContinued-stay review interval

7 daysPost-discharge follow-up

3MS-DRG codes listed

Acute Heart Failure Coverage Criteria

Initial inpatient admission

Acute inpatient admission is medically necessary when ALL of the following are met: at least one clinical severity finding AND at least one hospital-level service is required.

Inpatient admission

Clinical severity finding
- Hypoxemia: SpO2 below 90% on room air, or need for more than 4 L/min nasal cannula, high-flow nasal oxygen, or noninvasive ventilation.SpO2 <90%; oxygen >4 L/min
- Respiratory distress: Respiratory rate above 24 breaths per minute or dyspnea at rest (NYHA class IV) with radiographic pulmonary edema.RR >24/min
- Hypotension or hypoperfusion: Systolic blood pressure below 90 mm Hg, mean arterial pressure below 65 mm Hg, or any hypoperfusion finding, including lactate at least 2 mmol/L, oliguria, cool extremities, or altered mentation.SBP <90 mm Hg; MAP <65 mm Hg; lactate >=2 mmol/L
- Renal or sodium abnormality: Acute kidney injury or serum sodium below 130 mEq/L with congestion.Creatinine rise >=0.3 mg/dL within 48 hours or >=1.5 times baseline; sodium <130 mEq/L
- Natriuretic peptide with refractory congestion: BNP or age-stratified NT-proBNP is consistent with acute heart failure together with clinical congestion not responsive to initial emergency-department diuresis.BNP >=400 pg/mL; NT-proBNP >450 pg/mL if younger than 50 years, >900 pg/mL if age 50-75 years, or >1,800 pg/mL if older than 75 years
- Hypertensive pulmonary edema: Hypertensive acute pulmonary edema is present.SBP >160 mm Hg with pulmonary edema
- Arrhythmic or ischemic precipitant: Decompensation is precipitated by acute ischemia, troponin rise, new atrial fibrillation with rapid ventricular response, or sustained ventricular arrhythmia.
- New-onset heart failure has moderate or greater congestion, such as anasarca or pleural effusions, or unknown ejection fraction requiring same-stay echocardiography and etiologic evaluation.
Hospital-level service
- Intravenous loop diuresis: Repeated intravenous loop diuretic dosing or continuous infusion with urine output and electrolyte monitoring.Initial dose at least equal to, and typically 1.25 times, total daily oral dose
- Intravenous vasodilator: Intravenous nitroglycerin or nitroprusside titration.
- Infusion support: Inotrope or vasopressor infusion.
- Respiratory support: Noninvasive or invasive ventilation, or high-flow nasal oxygen.
- Telemetry:

Observation or outpatient management

Observation (expected 24–48 hours) or outpatient management is appropriate when ANY of the following applies and no inpatient severity finding is present.

Lower-acuity management

Mild exacerbation suitable for observation: Worsening by one NYHA class, SpO2 at least 92% on room air or 2 L/min or less, systolic blood pressure above 100 mm Hg, stable creatinine, and brisk response to one or two intravenous diuretic doses.SpO2 >=92%; SBP >100 mm Hg; more than 1 L urine output within 4–6 hours is an example of brisk response
Observation expected 24–48 hours
Mild exacerbation suitable for outpatient care: Weight gain below 2 kg with mild edema only, normal oxygen saturation, stable hemodynamics and renal status, and a plan to increase oral diuretic with clinic or telehealth follow-up within 48–72 hours.Weight gain <2 kg; follow-up 48–72 hours

Intensive care unit

ICU or cardiac ICU care is medically necessary when ANY of the following is present.

ICU level of care

Cardiogenic shock or vasopressor: Cardiogenic shock, SCAI stage C–E, or any vasopressor requirement.SCAI stage C–E
Inotrope instability: Inotrope infusion with hypotension, active titration, or invasive hemodynamic monitoring.
Severe respiratory failure: Invasive ventilation, or noninvasive ventilation with persistent respiratory acidosis or hypoxemia after 1–2 hours.pH <7.30

Step-down or intermediate care

Step-down or intermediate care is medically necessary when no ICU criterion is met and ANY of the following is present.

Improving respiratory support: Noninvasive ventilation or high-flow nasal oxygen with improving gas exchange.
Vasoactive or inotrope therapy: Intravenous vasodilator infusion, or stable low-dose inotrope without hypotension.
Continuous diuretic and electrolyte risk: Continuous intravenous loop diuretic with potassium below 3.0 mEq/L or above 5.5 mEq/L, or need for electrolyte checks every 6–8 hours.K <3.0 or >5.5 mEq/L; checks every 6–8 hours
Atrial fibrillation rate-control titration: Atrial fibrillation with rapid ventricular response requiring intravenous rate-control titration.

Medical-surgical unit

Medical-surgical unit care is appropriate when continued acute care is needed but no ICU or step-down criterion is met, including ANY of the following.

Medical-surgical care

Intermittent intravenous diuresis with daily electrolytes and stable hemodynamics.
Decreasing supplemental oxygen: Supplemental oxygen at 4 L/min or less and decreasing.<=4 L/min
Transition and therapy optimization: Transition to oral diuretic and initiation or titration of guideline-directed medical therapy.

Discharge readiness

The member is ready for discharge when ALL of the following are met.

Improved congestion: Weight is at or near target or edema is reduced to trace or baseline, and there is no orthopnea.
Stable oxygenation: SpO2 is at least 92% on room air or at the member's baseline oxygen prescription.SpO2 >=92%
Stable hemodynamics: Systolic blood pressure is at least 90 mm Hg without symptomatic orthostasis, and there has been no intravenous vasoactive therapy for at least 24 hours.SBP >=90 mm Hg; no IV vasoactive therapy >=24 hours
Stable oral diuresis:

Continued inpatient stay

Continued acute inpatient stay is medically necessary, with review every 24 hours, when ANY of the following is documented.

Continued stay

Ongoing congestion still requires intravenous diuretics, with documented daily response such as net fluid balance, weight, urine output, or natriuresis.
Diuretic resistance requires dose escalation, sequential nephron blockade, or ultrafiltration.
Cardiorenal syndrome: Worsening renal function with congestion requires daily adjustment.
Infusion therapy: Inotrope or vasodilator infusion or weaning is ongoing.
Uncontrolled arrhythmia:

Extended-stay review

The expected length of stay for an uncomplicated exacerbation is about 3–4 days. This is a planning benchmark, not a limit on covered days; extended-stay review occurs every 24 hours.

Extended-stay trigger: An extended stay is supported by diuretic resistance, cardiorenal syndrome, inotrope dependence or weaning, uncontrolled arrhythmia, new device implantation for a separate in-hospital indication, advanced-therapy evaluation, or infection or other complication requiring continued intravenous therapy without a feasible outpatient alternative.Expected stay about 3–4 days; review every 24 hours

Days beyond the expected stay must document the trigger, daily objective response, and plan.

Excluded conditions and services: Heart failure caused by acute coronary syndrome or acute myocarditis, as well as care involving durable mechanical circulatory support or transplantation, is outside the scope of this policy.

Admission for a mild weight gain or edema with normal oxygenation, stable hemodynamics, and stable renal function does not meet inpatient medical-necessity criteria. Outpatient diuretic adjustment with close follow-up or a short observation period is appropriate.

A continued stay solely for guideline-directed therapy titration does not meet acute inpatient criteria when the member is euvolemic, clinically stable, and receiving oral therapy. Titration can continue after discharge through early follow-up visits.

A continued stay solely to obtain an outpatient-appropriate test, such as elective ischemic evaluation or cardiac MRI, does not meet criteria when the member is stable.

After discharge-readiness criteria are met, days spent awaiting skilled nursing or home-health services without an acute need are considered custodial rather than acute-care days and do not meet acute criteria. These cases are referred for physician review and discharge planning; previously authorized days are not retroactively denied.

Coding and Clinical Threshold Reference

ICD-10-CM heart failureICD-10

I50.1	Heart failure
I50.20	Heart failure
I50.21	Heart failure
I50.22	Heart failure
I50.23	Heart failure
I50.30	Heart failure
I50.31	Heart failure
I50.32	Heart failure
I50.33	Heart failure
I50.40	Heart failure

1–10 of 23

1/3

ICD-10-CM hypertensive heart disease with heart failureICD-10

I11.0	Hypertensive heart disease with heart failure; sequence first with an I50 code per coding guidelines
I13.0	Hypertensive heart disease with heart failure; sequence first with an I50 code per coding guidelines
I13.2	Hypertensive heart disease with heart failure; sequence first with an I50 code per coding guidelines

ICD-10-PCS support proceduresICD-10

5A1D90Z	Support procedure example
5A02210	Support procedure example
5A0221D	Support procedure example

MS-DRG heart failure and shockmixed

291	Heart failure and shock
292	Heart failure and shock
293	Heart failure and shock

Revenue codesRevenue

0120	Revenue code
0121	Revenue code
0122	Revenue code
0123	Revenue code
0124	Revenue code
0126	Revenue code
0127	Revenue code
0128	Revenue code
0129	Revenue code
0200	Revenue code

1–10 of 33

1/4

Hypoxemia

Room-air oxygenationSpO2 below 90% on room air

Nasal-cannula requirementMore than 4 L/min nasal cannula

Advanced respiratory supportHigh-flow nasal oxygen or noninvasive ventilation

Respiratory severity

Respiratory rateAbove 24 breaths per minute

Resting dyspneaDyspnea at rest (NYHA class IV)

Provider Documentation and Review Actions

Documentation Required

Physician Review and Peer-to-Peer Process

Requests that do not meet the policy criteria must be referred for physician review. Automated systems and non-physician clinical reviewers may approve a request in full or in part, but may not issue an adverse determination; the requesting provider must be offered a peer-to-peer discussion before an adverse determination is issued.

Only a licensed physician of the same or similar specialty may issue an adverse determination.
The reviewing physician must also meet applicable licensure, specialty, and medical-director requirements of the plan's situs state.

Documentation Required

Continued-Stay Review

Apply concurrent review to each continued-stay period. Previously authorized days are not retroactively denied, and an expected length of stay is a planning benchmark rather than a limit on covered days.

Review each requested continued-stay period against the applicable criteria.
The Medicare two-midnight benchmark is not a coverage criterion for these commercial plans.

Clinical Background

Acute heart failure hospitalization is appropriate when objective congestion or hypoperfusion requires intravenous therapy and monitoring that cannot be delivered at a lower level of care. Mild exacerbations may instead be managed with intensified oral therapy, outpatient intravenous diuresis, close follow-up, or a short observation period.

Key Definitions

Congestion

DefinitionClinical or imaging evidence of elevated filling pressures

Clinical findingsElevated jugular venous pressure, rales, or peripheral edema

Pleural or pulmonary findingsPleural effusion or pulmonary vascular congestion or edema on imaging

Hypoperfusion

DefinitionEvidence of inadequate cardiac output

Clinical findingsCool extremities or altered mentation

Urine outputOliguria below 0.5 mL/kg/h

Policy Summary

PayerCurative

PolicyA003. Acute Heart Failure / Heart Failure Exacerbation

Policy CodePolicy N/A

Change TypeNo material change

Effective DateNovember 5, 2026

Next Review DateN/A

Key ActionDocument vital signs, oxygen requirement, and examination findings of congestion or hypoperfusion.

SourceLink

On This Page

Continuous telemetry for arrhythmia associated with decompensation.

Ultrafiltration or renal replacement therapy for diuretic-resistant congestion.

Temporary mechanical support: Temporary mechanical circulatory support.

Outpatient intravenous diuretic program:

A stable member has access to an outpatient intravenous diuretic clinic or home-based intravenous diuretic program.

Mechanical support or emergent advanced therapy:

Temporary mechanical circulatory support or evaluation for emergent advanced therapies.

Unstable ventricular arrhythmia: Sustained ventricular arrhythmia or arrhythmia with hemodynamic compromise.

The member has received an oral diuretic regimen for at least 24 hours without significant weight regain, generally less than 1 kg.

>=24 hours; weight regain generally <1 kg

Stable renal function and potassium: Creatinine is stable or improving for at least 24 hours and potassium is 3.5–5.0 mEq/L.K 3.5–5.0 mEq/L

Guideline-directed therapy plan: Guideline-directed medical therapy has been started or titrated, or a contraindication is documented.

Precipitant addressed: The precipitating factor has been identified and addressed.

Safe transition plan: The plan includes daily weight and sodium and fluid guidance, medication education, follow-up within 7 days or telephone contact within 3 days, and cardiac rehabilitation or home-health referral when indicated.Follow-up <=7 days; telephone contact <=3 days

An arrhythmia remains uncontrolled.

Advanced-therapy evaluation: Active inpatient evaluation for durable mechanical support or transplantation is occurring in a member who cannot be safely discharged.

Unable to tolerate oral medications: The member cannot tolerate oral medications.

Imaging findingRadiographic pulmonary edema with dyspnea at rest

Hemodynamic instability

Systolic blood pressureBelow 90 mm Hg

Mean arterial pressureBelow 65 mm Hg

LactateAt least 2 mmol/L

Acute kidney injury

Creatinine change within 48 hoursRise of at least 0.3 mg/dL

Creatinine relative to baselineAt least 1.5 times baseline

Clinical significanceMeets the acute kidney injury threshold for inpatient severity assessment

Hyponatremia

Serum sodiumBelow 130 mEq/L

Required associated findingClinical congestion

Admission criterionThe sodium abnormality is considered with congestion as a clinical severity finding

Natriuretic peptide

BNPAt least 400 pg/mL

NT-proBNP under age 50Above 450 pg/mL

NT-proBNP age 50-75Above 900 pg/mL

NT-proBNP over age 75Above 1,800 pg/mL

Required clinical contextClinical congestion not responsive to initial emergency-department diuresis

Hypertensive acute pulmonary edema

Systolic blood pressureAbove 160 mm Hg

Pulmonary findingPulmonary edema

Combined criterionSystolic blood pressure above 160 mm Hg with pulmonary edema

Observation response

Urine outputMore than 1 L

Response windowWithin 4-6 hours

Diuretic exposureAfter one or two intravenous diuretic doses

Persistent respiratory acidosis

pH thresholdBelow 7.30

OxygenationPersistent hypoxemia

Assessment timingAfter 1-2 hours of noninvasive ventilation

Electrolyte-based step-down criterion

Low potassiumBelow 3.0 mEq/L

High potassiumAbove 5.5 mEq/L

Monitoring frequencyElectrolyte checks needed every 6-8 hours

Discharge oxygenation

Room-air oxygenationSpO2 at least 92% on room air

Baseline oxygen useAlternatively, oxygenation is at the member's baseline oxygen prescription

Discharge requirementStable oxygenation must be present before discharge

Discharge renal and electrolyte status

CreatinineStable or improving for at least 24 hours

Potassium range3.5-5.0 mEq/L

Discharge requirementRenal function and potassium must be stable within the stated parameters

Discharge oral diuretic stability

Oral diuretic durationRegimen tolerated for at least 24 hours

Weight responseNo significant weight regain, generally less than 1 kg

Discharge requirementThe oral regimen must be tolerated without significant weight regain

Age-stratified NT-proBNP diagnostic cut points

Age under 50 yearsNT-proBNP cut point: 450 pg/mL

Age 50-75 yearsNT-proBNP cut point: 900 pg/mL

Age over 75 yearsNT-proBNP cut point: 1,800 pg/mL

Documentation Required

Clinical Severity

Document the member’s clinical severity, including vital signs, oxygen requirement, and examination findings demonstrating congestion or hypoperfusion.

Include relevant hemodynamic and respiratory findings.
Document findings that support the requested level of care.

Documentation Required

Laboratory Evaluation

Provide laboratory evaluation supporting the acute heart-failure assessment and treatment plan.

Natriuretic peptide
Creatinine and electrolytes
Troponin
Lactate when hypoperfusion is suspected

Documentation Required

Imaging and Cardiac Function

Include chest imaging and echocardiography results, including the ejection fraction, when documenting the acute heart-failure episode.

Provide the relevant chest-imaging findings.
Include echocardiographic cardiac-function findings and ejection fraction.

Documentation Required

Decongestion Monitoring

Document the clinical response to decongestion treatment throughout the stay.

Daily weights
Intake and output
Diuretic doses
Response to treatment

Documentation Required

Precipitating Cause

Identify and document the precipitating cause of the acute decompensation.

Link the documented cause to the acute presentation and treatment plan.

Documentation Required

Guideline-Directed Therapy

Document the guideline-directed therapy plan and the clinical reasons for omitting any drug class.

Identify planned guideline-directed therapies.
Explain the reason for each omitted drug class.

Documentation Required

Level of Care and Transition Plan

Provide daily justification for the current level of care and a discharge follow-up plan.

Document why the member continues to require the current level of care.
Include the planned discharge follow-up.

Documentation Required

Support Requested Services

Documentation must support the requested quantity, units, and duration. When the service meets criteria but the request exceeds the supported amount, approve the supported portion and review only the unsupported increment.

Support the quantity requested.
Support the units requested.
Support the duration requested.

Denial Risk

Mild Stable Exacerbation

Admission for mild weight gain or edema alone does not meet medical-necessity criteria when oxygenation, hemodynamics, and renal function are stable.

Outpatient diuretic adjustment with close follow-up or observation may be appropriate.
Requests in this circumstance are referred for physician review rather than denied by an automated system or non-physician reviewer.

Denial Risk

Therapy Titration Alone

A continued stay solely to complete guideline-directed therapy titration is not supported when the member is euvolemic and stable on oral therapy.

Therapy titration can continue after discharge at early follow-up visits.
Refer the request for physician review rather than issuing an automated or non-physician adverse determination.

Denial Risk

Outpatient-Appropriate Testing

A continued stay solely to obtain testing that is appropriate in the outpatient setting is not supported when the member is stable.

Examples include elective ischemic evaluation or cardiac MRI.
The stable member should receive testing at the appropriate site of care.
Refer the request for physician review rather than issuing an automated or non-physician adverse determination.

Denial Risk

Custodial or Placement Delay

Days spent awaiting skilled-nursing or home-health placement after discharge-readiness criteria are met do not support an acute continued stay when there is no acute need.

Custodial days do not meet acute criteria.
Refer for physician review and discharge planning.
Days already authorized are not retroactively denied.

Denial Risk

Red Flags Requiring Escalation

Escalate urgently when red-flag findings indicate shock, respiratory or neurologic deterioration, serious arrhythmia, or acute coronary syndrome.

Systolic blood pressure below 90 mm Hg with hypoperfusion, rising lactate, or oliguria below 0.5 mL/kg/h for 6 hours: transfer to ICU and evaluate for cardiogenic shock; consider inotropes or mechanical support.
Worsening hypoxemia or hypercapnia despite noninvasive ventilation, or declining mental status: initiate rapid response and consider intubation and ICU care.
New sustained ventricular tachycardia, symptomatic bradycardia, or syncope: escalate to telemetry or ICU and obtain electrophysiology evaluation.
Chest pain with dynamic ECG changes or rising troponin: evaluate for acute coronary syndrome under Policy A001 or A002.
Potassium above 6.0 mEq/L or creatinine rising more than 0.5 mg/dL per day: urgently adjust medications and obtain renal evaluation.
Persistent congestion, rest dyspnea, or hypotension at planned discharge: discharge is unsafe; continue acute care.

Billing Rule

Unsupported Quantity, Units, or Duration

When the service meets criteria but the requested quantity, units, or duration exceed what the documentation supports, approve the supported portion and separately review only the unsupported increment.

Do not deny the supported portion solely because the full request exceeds the documented support.
Document the specific unsupported quantity, units, or duration under review.

Documentation Required

Physician Review for Adverse Determination

Requests that do not meet criteria must be referred to a licensed physician of the same or similar specialty for review. The physician must offer the requesting provider a peer-to-peer discussion before issuing an adverse determination.

Automated systems and non-physician clinical reviewers may not issue an adverse determination.
The reviewing physician must satisfy applicable licensure, specialty, and medical-director requirements of the plan's situs state.
The absence of a criterion addressing a service is not itself a basis for an adverse determination; the physician applies generally accepted standards of medical practice.

Laboratory findingsLactate at least 2 mmol/L or worsening renal or hepatic function

Diuretic resistance

DefinitionInadequate natriuresis or urine output despite an appropriately dosed intravenous loop diuretic

Spot urine sodiumBelow 50-70 mEq/L at 2 hours

Urine outputBelow 100-150 mL/h during the first 6 hours

Guideline-directed medical therapy

Renin-angiotensin system therapyRenin-angiotensin system inhibitor, preferably ARNI

Additional medication classesEvidence-based beta-blocker and mineralocorticoid receptor antagonist

SGLT2 inhibitorIncluded for reduced ejection fraction and also recommended across mildly reduced and preserved ejection fraction