Appeal type: Medical necessity
Decision: Upheld

This is a patient with a past medical history significant for polycystic kidney disease, polycystic liver, end-stage renal disease, status post kidney transplant, and hypertension who presented to the hospital with complaints of shortness of breath that had been going on for 2 weeks. The patient stated that he had been coughing, especially when he tried to take a deep breath.
The patient also complained of abdominal distention, which was attributed to his polycystic kidney disease. In general, he stated that his symptoms were worsening over the course of 2 weeks.
The patient stated that in the past he had episodes of shortness of breath that were attributed to volume overload due to his end-stage renal disease, which required hemodialysis. The review of systems was positive for abdominal distention but negative for fever, chills, diarrhea, constipation, or blood in the stool.
In the emergency department (ED), the patient received treatment with intravenous Lasix, which according to the patient did not provide relief of his symptoms. In the ED he also underwent a computed tomography (CT) scan of the abdomen and pelvis, as well as a CT angiogram of the chest. In general, there were no major changes revealed by these studies.
At the time of the initial evaluation, the patient's temperature was 37.2 degrees Centigrade (C), heart rate 68 beats per minute (bpm), blood pressure 119/70, respiratory rate 20, and oxygen saturation 99% on room air.
At the time of the initial evaluation performed by the admitting physician, the patient was not in acute distress, the head, eyes, ears, neck, throat (HEENT) exam was within normal limits. Lungs were clear to auscultation without rhonchi, rales, or wheezing. The cardiovascular exam was unremarkable. The patient's abdomen was soft, nondistended, tender to palpation diffusely, with positive bowel sounds. The rest of the physical exam was unremarkable. The CT scan of the abdomen demonstrated no change in innumerable hepatic and renal simple and complex lesions, consistent with polycystic kidney disease. CT scan of the chest showed no pulmonary embolism, clear lungs.
The patient was admitted to the hospital because of shortness of breath, which was attributed to abdominal distention from worsening polycystic disease of the liver and kidneys.  It was indicated that the patient had a renal transplant, therefore the plan was to continue treatment with CellCept and Tacrolimus, also to continue Sensipar and Lasix.
In the hospital, the patient was seen by the cardiology service. They evaluated the patient for shortness of breath. It was suggested that the patient's dyspnea was likely related to abdominal distention. It was mentioned in the consultation note that the patient was euvolemic on the exam. The cardiologist recommended continuing a home regimen of Lasix. There was no further need for cardiac evaluation as an inpatient.
The case was discussed with the interventional radiologist in regard to the necessity of draining a big renal cyst. The interventional radiologist suggested no further interventions.
Nephrology consultation was requested, but the patient decided to leave the hospital against medical advice.
The health plan's determination is upheld.
This is a patient with a known history of polycystic kidney disease with multiple cysts in the kidneys and the liver. He presented to the hospital with progressively increasing shortness of breath. Objectively, this patient was afebrile and hemodynamically stable, had normal respiratory rate, and normal oxygen saturation. The patient was not in acute respiratory distress. His lungs were clear to auscultation, there were no signs of congestive heart failure. Laboratory studies looked reassuring. There was no evidence of pulmonary embolism on the CT scan of the chest, no infiltrates, pleural effusions, or pneumothorax.
The patient was evaluated by a cardiologist and was recommended no further cardiac workup. There was no evidence that the patient required any procedure or surgery necessitating admission at an acute inpatient level of care.
Taking into consideration all of this information, there was no reason for admission at an acute inpatient level of care.