Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System. 
Treatment: Inpatient Hospital. 
The insurer denied: Inpatient stay. 
The denial is upheld in whole.

This is the case of a male with past medical history of congestive heart failure, sleep apnea, paroxysmal atrial flutter, oligodendroma status post partial resection, aortic valve replacement, mitral valve repair, and stable cerebral and thoracic artery aneurysms, who presented to the emergency department with cough, weakness, gait instability, and shortness of breath for the past 4 days.
On presentation, he was febrile to 102.8 with blood pressure 117/70, heart rate 133, respiratory rate 17, and with oxygen saturation 98% on room air. Exam otherwise noted crackles and rhonchi on pulmonary exam and no focal neurologic deficits. Labs resulted with white blood cell (WBC) 10.9, hemoglobin (HGB) 15.3, platelets 189, sodium 139, potassium 3.7, blood urea nitrogen (BUN) 21, creatinine 1.28, international normalized ratio (INR) 1.2, troponin normal, and venous blood gas with pH 7.44 and partial pressure of carbon dioxide (pCO2) 30.6. Influenza and clostridium difficile testing were negative. Computed tomography (CT) of the head and magnetic resonance imaging (MRI) of the brain showed no acute process. Chest x-ray showed no focal consolidation or pleural effusions. Electrocardiogram (EKG) was notable for atrial flutter with a rate of 114. The patient was given ceftriaxone, vancomycin, and Lopressor intravenous (IV) in the emergency department. He was brought into the hospital with concern for cough and possible upper respiratory infection versus pneumonia and atrial flutter with rapid ventricular response and with initial plan for ongoing scheduled metoprolol and IV antibiotics with telemetry monitoring, neurology, cardiology, and infectious disease consultations.

Neurology subsequently saw the patient with no further neurologic work-up recommended. Infectious disease saw the patient with recommendation to obtain CT of the chest given clinical suspicion for possible pneumonia and to continue antibiotics and follow up blood cultures. Cardiology saw the patient with assessment that his aflutter with rapid ventricular response was triggered by his upper respiratory tract infection and to be cautious with rate control in this setting.
The patient had no further fevers and his mild leukocytosis resolved. Antibiotics were discontinued and the patient was subsequently discharged.

This is a patient who presented with fever, atrial flutter with mild rapid ventricular response in the 110 range, and with cough and weakness suggestive of upper respiratory tract infection versus frank pneumonia. The patient's heart rate improved rapidly with one dose of Lopressor in the emergency department followed by initiation of oral metoprolol and he remained hemodynamically stable throughout the hospitalization without further tachycardia, hypotension, or hypoxia. Otherwise, his leukocytosis improved quickly, and he was able to be discharged within a reasonable period of monitoring and without ongoing antibiotics. In the absence of hemodynamic instability, hypoxia, pneumonia deemed to be high risk with PSI/PORT score of IV (this patient's was III), renal failure, or other clear acute process requiring hospital-level care, this patient could have been treated at a lower level of care status.