Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiomyopathy
Treatment: Inpatient Admission
The insurer denied: Inpatient Admission
The denial is: Upheld

The patient is a male with a past medical history significant for hypertension, possible coronary artery disease, atrial fibrillation, and nonischemic cardiomyopathy who presented to the emergency department with complaints of generalized weakness and nausea.
The patient recently underwent a transesophageal echocardiogram two weeks before the presentation and was scheduled for a cardiac catheterization.
When the patient was seen by the admitting physician he denied chest pain, palpitations, shortness of breath, dizziness, nausea, vomiting, abdominal pain, or any other symptoms.
He was afebrile. The blood pressure was 128/82, heart rate 87 beats per minute (bpm), respiratory rate 19 breaths/minute, and oxygen saturation 100% on room air.
The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. The neck was supple without lymphadenopathy, masses, jugular vein distention (JVD), and carotid bruits. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. Lungs were clear to auscultation without wheezes, rales, or rhonchi. The abdomen was soft, non-tender to palpation, with normal bowel sounds, without guarding or rebound. On the neuro exam, the patient was alert and oriented x 4. He had normal strength in the extremities and demonstrated normal behavior.
Laboratory evaluation revealed that sodium was 141, potassium 4.8, chloride 101, bicarbonate 25, blood urea nitrogen (BUN) 7, creatinine 1.25, and glucose 129. Magnesium was 1.3. White blood cell count was 13.5, hemoglobin 16.7, hematocrit 52.5, and platelets 369. International normalized ratio (INR) was 1.1. Chest x-ray demonstrated no gross pulmonary pathology.
The patient was admitted to the hospital with a diagnosis of weakness, congestive heart failure (CHF), to rule out acute coronary syndrome, mild leukocytosis, hypogammaglobinemia, and dehydration.
The admitting physician ordered a urinalysis and urine culture.
During the hospital stay, the patient was seen by a cardiologist who performed an angiogram, which revealed two-vessel coronary artery disease. Percutaneous coronary intervention (PCI) was performed.
Following the procedure, the patient was treated with Aspirin, Brilinta, and Eliquis.
The patient was deemed stable for discharge home, with recommendations to follow up with a cardiologist as an outpatient.
The subject under review is the medical necessity for an inpatient admission.

The health plan's determination is upheld.

The inpatient admission was not medically necessary for this patient.
The patient presented to the hospital with nonspecific symptoms including generalized weakness and difficulties with ambulation. The review of the medical records did not show strong evidence that he had an acute coronary syndrome. His EKG(electrocardiogram) demonstrated nonspecific T wave changes and the serum troponin levels were only minimally elevated. The patient was already scheduled for a coronary angiogram, which was performed according to the schedule. The review of the medical records did not demonstrate that the patient had evidence of acute exacerbation of congestive heart failure or any respiratory issues including hypoxemia or persistent tachypnea. Furthermore, this patient was afebrile and hemodynamically stable. His physical exam was unremarkable, and the results of the laboratory studies were not alarming.
Even though the patient had a slightly elevated white blood cell count, there was no strong evidence of infection necessitating the administration of intravenous antibiotics. The results of the imaging studies also did not show any acute abnormalities necessitating admission at the acute inpatient level of care.