Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infectious Disease. 
Treatment: Inpatient Hospital. 

The insurer denied Inpatient Stay. 
The denial is upheld. 

The patient is a male with a past medical history of gastroesophageal reflux disease (GERD) who presented to the hospital with complaints of palpitations and fever. Reportedly, he had been recently evaluated in the emergency department for shortness of breath and fever. The workup was negative, and he was discharged home with a recommendation to follow up as an outpatient. While at home, the patient spiked a fever up to 102F. He stated that his heart was racing, and he was feeling lightheaded. 
According to the history and physical (H&P) note, the patient's oxygen saturation was in the 80's when he performed pulse oximetry at home. The review of systems was positive for chronic dry cough which was attributed to his GERD symptoms. Upon initial evaluation in the emergency department, the patient underwent a computed tomography (CT) angiogram of the chest that demonstrated no evidence of pulmonary embolism but revealed scattered bilateral opacities. When the patient was seen by the admitting physician, he was afebrile. The head, eyes, ears, neck, throat (HEENT) exam was within normal limits. The neck was supple without lymphadenopathy, masses, jugular vein distention (JVD), or carotid bruits. The patient was admitted to the hospital with a diagnosis of fever. It was reported that the patient had a fever at home but was afebrile in the emergency department. The admitting physician suspected that the scattered bilateral opacities in the lungs were not related to a bacterial infection. Viral infection or inflammatory process was suspected to be the diagnosis. 
Another clinical diagnosis was palpitations. It was mentioned that the patient's heart rate went up to the 170's, therefore telemetry monitoring was introduced. By the time the patient was seen by the admitting physician, the palpitations resolved. The admitting physician suspected that the patient could have supraventricular tachycardia, therefore an echocardiogram was ordered. 

During the hospital stay, the patient was monitored for antibiotics. It was mentioned that he received one dose of azithromycin on the second day of his hospitalization. The echocardiogram was performed and did not demonstrate significant abnormalities. During the hospital stay, the patient did not experience any symptoms since the time of admission. Therefore, he was discharged home with a recommendation to follow up with a cardiologist. 
At issue is the medical necessity of the Inpatient Stay. 

The health plan's determination of medical necessity is upheld in whole. 

The requested health service/treatment of Inpatient Stay was not medically necessary for this patient. 
Even though the patient reported fever and palpitations before his presentation to the hospital, while in the emergency department he was afebrile and had a mildly elevated heart rate. It was mentioned that the patient had scattered infiltrates on the CT scan of the chest, however, there were no signs of respiratory distress. His respiratory rate was 18 breaths per minute, and oxygen saturation was 100% on room air. The review of the medical records did not demonstrate any signs of hemodynamic instability.  During the short hospital stay, the patient remained afebrile and hemodynamically stable. It is unclear from the documentation why the patient received Azithromycin while being afebrile and having a normal white blood cell count. The infiltrates found on the CT scan of the chest did not require any procedures or treatments necessitating admission at the acute inpatient level of care. 
Overall, the patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. 
Therefore, the requested health service/treatment of Inpatient Stay was not medically necessary.