Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infectious Disease/Viral Infection; Influenza A.
Treatment: Inpatient Hospital stay.

The health plan denied the requested inpatient hospital stay. The health plan's determination is upheld.

The patient is a female with a past medical history significant for diabetes mellitus, hypertension, and hyperlipidemia who came to the hospital with complaints of dizziness and fatigue. The patient denied any falls, neck pain, nausea, recent diarrhea, blood loss, or head injury. At the time of the initial evaluation, she denied fever, chills, nausea, vomiting, headache, changes in vision, chest pain, palpitations, abdominal pain, shortness of breath, productive cough, diarrhea, constipation, urinary changes, focal deficits, or lower extremity edema.

The patient's temperature was 37C., with a blood pressure of 108/63 millimeters of mercury (mmHg), a pulse rate of 97 beats per minute (bpm), a respiratory rate of 20 breaths/minute, and an oxygen saturation of 99% on room air. The patient looked ill but not toxic or diaphoretic.

The head, eyes, ears, neck, throat (HEENT) exam was within normal limits. The patient had a regular rate and rhythm, without murmurs, rubs, or gallops. Lungs were clear to auscultation without wheezes, rales, or rhonchi. The abdomen was soft, nontender to palpation, with normal bowel sounds, without guarding or rebound. The rest of the physical exam was unremarkable.

Laboratory evaluation revealed that the white blood cell count was 8.3, with a hemoglobin of 14.4, a hematocrit of 45.6, platelets of 339, a sodium of 136, a potassium of 5.3, a chloride of 103, a bicarbonate of 22, a blood urea nitrogen (BUN) of 27.6, and a creatinine of 0.97. The liver function test was within normal limits. A computed tomography (CT) scan of the head was interpreted as normal.

The patient was admitted to the hospital with a diagnosis of dizziness without syncope.
An echocardiogram, and carotid duplex were ordered. The patient received Meclizine. For the influenza A infection, the patient was started on Tamiflu. The echocardiogram demonstrated normal left ventricular systolic function. The ejection fraction was estimated at 65-70%. The carotid duplex study was unremarkable. The patient was seen by a neurologist who suggested that the reason for her symptoms was unlikely neurological.

The patient's clinical condition gradually improved, and the patient was discharged from the hospital.

At issue is the medical necessity for the inpatient stay.

I uphold, in whole the health plan's determination of medical necessity.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.

The review of the medical records clearly demonstrated that the patient's influenza A infection was not associated with hypoxemia, hemodynamic instability, significant dehydration, or electrolyte abnormalities. There was no mention that the patient was unable to maintain oral hydration or had altered mental status. There was no evidence that the patient had an arrhythmia of immediate concern or any other unstable clinical conditions that would explain the dizziness or fatigue. The patient's symptoms were likely triggered by an influenza infection and possibly very mild dehydration.
The patient did not need any diagnostic test or intervention that would require admission at the acute inpatient level of care.

Therefore, the admission to an alternate level of care would have been the most appropriate, to ensure clinical stability as well as a safe discharge.

There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at an alternate level of care, rather than admission to an inpatient level of care. Neither the severity of the patient's condition nor the complexity of the services provided rose to the level of acute inpatient care.