Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory Problems
Inpatient Hospital

Diagnosis: Chest Pain, Left-Sided Community-Acquired Pneumonia
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The health plan's determination is upheld.

The patient is a female with multiple medical problems who presented to the emergency department (ED) with light headedness. Her family members reported confusion and there was a concern about a possible stroke. According to the ED note, she presented with generalized weakness and confusion for one day. According to the admitting team, who saw the patient in the ED, the patient complained of mid sternal chest pain since her arrival to ED and productive cough for a few months. 
The patient has a history of hypertension (HTN), hyperlipidemia (HLD), paroxysmal atrial fibrillation (on Xarelto), deep vein thrombosis (DVT), peripheral artery disease (PAD), left femoral-popliteal bypass with no further intervention as per vascular surgery and right common femoral artery stent, glaucoma and chronic obstructive pulmonary disease (COPD)/asthma. Her blood pressure (BP) was 90/52, heart rate 66 beats per minute (BPM), peripheral capillary oxygen saturation (SpO2) was 100 percent (%), and her temperature was normal.
The physical examination was unremarkable, her lungs were clear, her heart was regular, her chest had tenderness on palpation in the area of the chest pain and her abdomen was soft. Her lower extremities (LE) were without edema.
Her laboratory studies revealed a hemoglobin (Hb) of 8.2, potassium 2.9, creatinine 2.2 and her troponin was negative. Her procalcitonin was 0.16. Her international normalized ratio (INR) was 3.8. The urinalysis was abnormal with evidence of urinary tract infection (UTI).
Her electrocardiogram (ECG) revealed sinus bradycardia at 58 BPM with nonspecific ventricular repolarization (T) wave changes in the anterolateral leads. The chest x-ray (CXR) revealed a left lung base infiltrate.
The impression was that her lightheadedness and hypotension was due to blood loss, possibly related to anticoagulants and anti-hypertensives. Her hemoglobin dropped, it is 8.2 and it was 11 last month. Her acute kidney injury was probably due to dehydration with hypokalemia, possibly due to diuretic use. Her baseline creatinine was 0.8. Also, the diagnosis of a UTI, possible pneumonia was entertained. The patient underwent a computed tomography (CT) of the head and it was unremarkable beside age related changes.

While in the ED, the patient was treated with intravenous fluids (IVF). Her fecal occult blood was positive. The patient received Potassium and was started on the intravenous antibiotics Vancomycin and Zosyn. The patient was admitted to the hospital. She was started on IVF and her anti-hypertensives were held. The patient was started on antibiotics by mouth (PO). Her lethargy and lightheadedness resolved. She continued to have chest pain. Her serial troponin was negative. Her chest pain was contributed to costochondritis. 
The requested health service/treatment of inpatient hospital admission was not medically necessary for this patient. The patient presented with hypotension, anemia and acute kidney injury. The patient responded well to IVF and her BP was stable for the rest of the hospital stay. There was a suspicion of pneumonia, but the CT of the chest ruled out pneumonia. Her urine culture was negative. Her creatinine normalized after IVF. Her Hb was low, but there was no evidence of acute blood loss. The gastroenterologist recommended an endoscopy, but it was not done during this admission. Her serial troponin was negative and her chest pain was felt to be of musculoskeletal origin. Her echocardiogram was unremarkable. Transient hypotension, which responded well to fluid bolus, plus elevated creatinine, which improved with IVF, could have been managed at an alternate level of care. Her chest pain was not cardiac. She did not have pneumonia or UTI.