Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pulmonary infarct of the left lung and question for septic emboli.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is overturned.

The patient is an adult male that was brought to the emergency department by ambulance for eight out of ten pleuritic chest pain, chills and hemoptysis. He looked cachectic and critically ill in the Emergency Department, with voluntary splinting, tenderness to palpation of the left anterior chest wall between the seventh and eighth ribs, his skin was pale with well-demarcated 0.5 to one centimeter healing surgical plaque-like lesions with punctate appearing centers bilaterally on his hands and forearms.
A Grade 2/6 murmur was heard. The patient's chest x-ray was positive for new dense consolidation in the left lower lobe, suspicious for pulmonary infarction. There were small peri-bronchial infiltrates bilaterally, and of these lesions, some appeared chronic, and some appeared acute. The initial vital signs were temperature 37.5 degrees Celsius (C), heart rate 94 beats per minute, respirations 26 per minute, oxygen saturation level of 100% on room air, and blood pressure of 117/94.  Cardiology and Infectious Disease consultants were also called. 
On day#2, the patient continued to have left lateral chest and back pain, worse with inspiration and intermittent hemoptysis. He received intravenous Toradol. Echo showed moderate-large tricuspid valve vegetation measuring 1.3 by 1.2 centimeters; moderate-severe tricuspid regurgitation (overall slightly smaller vegetation than prior). Cardiology indicated pulmonary infarction and septic pulmonic embolism. Tricuspid valve endocarditis was now considered sterile, though there was a residual one-centimeter vegetation. Agreed with anticoagulation and waited for Infectious Diseases (ID) consult. 
On day #3, Infectious Diseases (ID) consult indicated a new pulmonary infarct and perhaps recurrent pulmonary embolism. The patient remained with a vegetation on his tricuspid valve but 
blood cultures were negative thus far. Agreed with anticoagulation and continued to monitor blood cultures.
The patient was by then significantly improved and he denied significant dyspnea. The patient continued to have chest pain rated as eight to nine out of ten (8-9/10), for which he received intravenous Toradol times two. Prior to obtaining blood culture results and performing repeat culture, the patient was advised to remain in the hospital for an additional 12 to 24 hours, but he left against medical advice.

The proposed inpatient hospital admission was medically necessary.

The health plan denied authorization on the basis of "pulmonary embolism," which was not a correct admitting diagnosis. This was a young, chronically ill patient with a complex medical history who was admitted for possible recurrent endocarditis, sepsis, septic emboli and pulmonary infarction. This was not a simple case, but a complex medical illness in a patient with a known history of intravenous drug use, endocarditis with valvular vegetations and septic emboli to the lung. The risk of further complications, including death, was significant. Treatment for this patient required inpatient admission. Sepsis and possible recurrent endocarditis and with septic embolization is a life-threatening condition that requires inpatient treatment.