Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of Breath
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

This patient is an adult female who presented to the emergency department at South Nassau Communities Hospital with the compliant of shortness of breath. She had undergone laparoscopic takedown of a fundoplication, repair of hiatal hernia and roux en Y gastric bypass last year. Comorbid health conditions included hypertension, Lupus, anastomotic bleeding and post-surgical infection treated by percutaneous drainage that complicated the bariatric procedure. The patient's vital signs at presentation included a normal temperature, blood pressure of 144/77 millimeters of mercury (mmHg) and a pulse of 72 to 99. The patient's oxygen saturation was 98-100% (percent). The patient was evaluated with physical exam, lab data, computed tomography (CT) scan of chest, abdomen, and pelvis, chest x-ray, right upper extremity duplex, and electrocardiogram (EKG). The white blood cell (WBC) count was normal. There was no imaging evidence for pulmonary embolism or pulmonary infection. The computed tomography scan showed a gastro-gastric fistula and mild inflammation in the right mid abdomen at the site of the prior drainage catheter. The patient was admitted to the hospital for further evaluation of dyspnea. She was started on a bariatric chopped diet. 
On Day 2, the patient was hemodynamically stable. A pulmonary consultation was requested for exertional dyspnea. A lower extremity duplex was performed to assess for deep venous thrombosis (DVT).
On Day 3, the patient's vital signs remained normal, and the duplex scan was negative for deep vein thrombosis (DVT). She reported feeling better and was deemed to be stable for discharge from the hospital. Outpatient pulmonary follow up was offered.
The health plan rationale for denial per the letter is that there is no documentation of a significant medical condition that required hospital admission. Per the denial letter from the Plan, criteria for full hospital admission were not met as there was no documentation of infection, trouble breathing, or blood pressure problems. This health plan determination was based on Milliman Care Guidelines (MCG), Pulmonary Disease.

The records do not support that inpatient admission was medically necessary.

The care and treatment provided to this patient could have reasonably been administered at a lower level of care than inpatient.
This patient presented to the hospital with complaint of shortness of breath. The patient was clinically stable at the time of presentation and remained stable throughout the hospitalization. The initial white blood cell (WBC) count was normal. Liver enzymes and renal function were normal. The evaluation with 
computed tomography of the chest/abdomen/pelvis and right upper extremity and bilateral lower extremity duplex scan was negative for pulmonary embolism, deep vein thrombosis, or other acute pathology. The patient was tolerating an appropriate post-bariatric diet. Based on the available medical record the medical necessity of inpatient admission is not established. The records support the health plan contention that this care and treatment provided could have been completed at a lower level of care. A lower level of care would still have allowed for provision of the medical treatment that was rendered in this case (including monitoring).