Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld in whole.

The patient is a male with past medical history significant for intermittent asthma and hypertension (HTN) of childhood. He was on Enalapril for one year which was stopped by pediatric nephrologist in view of normal blood pressure. On the day of admission, he was referred from his pediatrician office for admission to the pediatric floor for evaluation of high blood pressure and feeling of fatigue, malaise, headache, associated with photophobia and poor oral intake for past 3 weeks. Blood Pressure (BP) measured at the pediatrician office was 153/82. 
In the emergency room (ER) initial vital signs heart rate (HR) 88, BP was 144/73, respiratory rate (RR) was 18, oxygen (O2) saturation was 99% on room air (RA), Temperature was 98.8. The ER doctor reports the patient's pediatrician wanted him to be admitted for several tests. He described him as well appearing and ambulating with steady gait. In the ER comprehensive metabolic panel (CMP) and complete blood count (CBC) were unremarkable. Urinalysis (UA) concentrated with specific gravity (SG) greater than (>) 1030, protein trace and ketones > 80. Chest x-ray (CXR) was reported as normal. He was admitted to the pediatric floor. Vital signs showed BP 140/78, Temperature of 99.1, HR 81, and O2 saturation of 99%. Physical exam was unremarkable aside from 2/6 murmur noted to lower left sternal border (LLSB). Admission assessment reports admission for evaluation of fatigue, malaise, headache, anorexia associated with chest tightness, trouble breathing, nausea and elevated blood pressures. During the hospital course the patient was hemodynamically stable with some daytime blood pressure readings fluctuating from 130-145 systolic. Overnight readings were within normal limits (WNL). UA was repeated and was unremarkable. Nephrology consult was obtained, the patient to follow up in the nephrology clinic after discharge. While admitted the patient had no mention of fatigue, chest pain, blurry vision, he tolerated food without nausea, and was ambulating well. He was voiding and stooling adequately. He was screened and noted to have mild anxiety and mild depression. On day of discharge patient had no issues overnight. BP normal overnight and the day of discharge. At discharge patient was instructed to follow up with primary medical doctor  (PMD), nephrology, Cardiology and Ophthalmology. The subject under review is the medical necessity for the inpatient stay.

The inpatient stay was not medically necessary for this patient. This patient presented with symptoms of fatigue, malaise, headache, anorexia associated with chest tightness, trouble breathing, nausea and elevated blood pressures. BP at his PMD office was 153/82 and upon presentation to the ER it was 144/73. In the ER, the patient was described as well appearing and ambulating with steady gait. He also admitted he feels anxious for small things and gets nervous whenever he has to go to doctors' offices.  There was no mention of respiratory distress or complaints of difficulty breathing. The patient did not require any IV medication to control his blood pressures. He did not receive any antihypertensive while in house. His care consisted of routine vital signs, intravenous fluids (IVF) and evaluation by specialists on consult. His electrocardiogram(EKG) was normal. Two days prior at outside hospital his cardiac enzymes were within normal limits. He was not hemodynamically unstable with signs of altered mental status, end organ failure, seizure or papilledema. The patient did not meet any of Milliman Care Guidelines (MCG) criteria for pediatric inpatient admission. The inpatient level of care was not medically necessary for this patient.