Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a male. He presented with chief complaint of fatigue and an infected thumb. He also complained of SOB (shortness of breath). The patient has history of hypertension, CABG (coronary artery bypass graft), and diabetes. 

The patient was initially hypertensive. His exam was normal. The patient's creatinine was 1.5. His troponin was negative. Medication non-compliance was noted. The patient was initially hypertensive, and responded to oral medication. Ascites was discovered and plans for work up were made. The patient was discharged with diagnosis of SOB (shortness of breath) and chest pain of unknown etiology. 

The health plan's reason for denial was that care provided did not require an inpatient admission. The appeal was to reconsider this decision. 

No, the Inpatient admission was not medically necessary. 

Determination of level of care is primarily dependent on the actual care a patient receives, and whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results. It is highlighted in the orders for care. 

In this case, the patient's symptoms were dizziness, cold sweat and mild SOB (shortness of breath), thought to be secondary to missed BP (blood pressure) medications, as the patient was hypertensive. He was admitted to observe after medications restarted, it was unlikely to be representative of acute coronary syndrome or major illness. The patient's exam (BP [blood pressure] normalized) and cardiac findings were normal. Biomarkers and EKG (electrocardiogram) showed no evidence of acute ischemia. CXR (chest x-ray) was negative for cardiac pathology. CT (computed tomography) was negative for PE (pulmonary embolism). The physicians' treatment did not reflect any serious concern about patient's cardiac condition.  Orders did not include medical therapy for ACS (acute coronary syndrome), such as IV (intravenous) heparin, dual anti-platelet inhibitors, high dose beta blockers or IV (intravenous) NTG (nitroglycerin). 

The letter of appeal was carefully considered, but it offered no evidence to support inpatient level of care. The only cardiac care that was provided was telemetry, which is frequently performed in a lower level of care. The patient was admitted for monitoring, and the subsequent tests and therapy did not require an inpatient level of care. 

There was no "complex" care that required an inpatient level of care in this patient's care. This patient had no evidence of active CAD (coronary artery disease). 

The finding of ascites did not lead to a work up or treatment that required inpatient care. 

While there was always a potential for an adverse event, one did not happen, and no actual treatment was added. Milliman criteria requirements for inpatient care were not fulfilled. 

All of the testing and therapy that were provided would have been appropriate, safe and guidelines consistent in a lower level of care. Thus, inpatient level of care was not medically necessary. 

The denial explanation was consistent with guidelines and usual community care.