Appeal type: Medical necessity
Decision: Upheld

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

The patient is a morbidly obese female with a history of hypertension. She presented to the emergency department complaining of two months of productive cough and dyspnea. A recent echocardiogram had shown normal left ventricular systolic function. In the emergency department her blood pressure as 171/74 millimeters of mercury (mmHg) with a heart rate of 108 beats/minute. Her respiratory rate was 20/minute with a room air oxygen saturation of 95%. Her cardiac and pulmonary physical exams were unremarkable. Her electrocardiogram was normal. Chest x-ray showed cardiomegaly and "congestion". Her serum troponin level was normal. Her N-terminal brain natriuretic peptide (BNP) level was modestly elevated. Her D-dimer level was mildly elevated. Chest computed tomography (CT) angiography was indeterminate for a pulmonary embolism. The patient's white blood cell count was 21,580/cubic millimeter (cumm). A ventilation-perfusion (V/Q) scan was recommended to rule out pulmonary embolism. This could not be accomplished immediately, and the patient was admitted to the hospital to rule out pulmonary embolism. She was treated with anticoagulation, intravenous furosemide, nebulizers and steroids. She was seen in consultation by a pulmonologist who opined that her symptoms were due to bronchitis. The steroids were discontinued, and she was treated with oral antibiotics. The V/Q scan was performed and showed no evidence of pulmonary embolism. The patient was discharged. Medical necessity for an inpatient admission is at issue.

The health plan's determination is upheld in whole. 

The inpatient hospital admission was not medically necessary for this patient.
This patient presented with cough and dyspnea. There was a concern for pulmonary embolism, which was eventually ruled out. Her symptoms were attributed to congestive heart failure and bronchitis.
Regarding the possibility of pulmonary embolism, the patient was hemodynamically stable, without hypoxia. CT scan was nondiagnostic. From the records provided, it appears as if the primary reason for the patient's admission was to await a V/Q scan. An inpatient level of care was not justified on this basis.

Regarding congestive heart failure, the patient was hemodynamically stable, in normal sinus rhythm and did not have high risk features such as hyponatremia, elevated troponin level, marked BNP elevation or acute kidney injury. In heart failure patients, such as this patient, without high risk features, studies have shown that treatment at a lower level of care status is safe and effective, with similar outcomes, including readmission, repeat emergency department visits and 30 day mortality, when compared to those treated as inpatients. Thus, in this instance, treatment at a lower level of care status would have been appropriate; an inpatient admission was not medically necessary.

Regarding bronchitis, the patient was afebrile and not hypoxic, her pulmonary exam was unremarkable. Her bronchitis was treated with oral antibiotics. This did not require an inpatient level of care. The Milliman Care Guideline for Heart Failure (ORG: M-190) was reviewed. Per this document, this patient met none of these criteria for inpatient admission.