Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pulmonary embolism.
Treatment: Inpatient admission. 
The insurer denied coverage for an inpatient admission.
The denial is upheld.

The patient is a female who presented to the emergency department (ED) with complaint of a productive cough and some left sided chest pain. The patient has a past medical history (PMH) of hypertension (HTN), hyperlipidemia (HLD), and syncope.

At presentation to the emergency department (ED) the initial vital signs at triage were: Temperature 99.4 F (Fahrenheit), Blood Pressure 154/92, Heart Rate 147, Respiratory Rate 20, and oxygen (O2) saturations was 97% on Room Air.

The patient was in no acute distress (NAD). Some diaphoresis was noted. The lung exam revealed some rhonchi.

The patient was alert and oriented. Labs: White blood cell count (WBC )5.8, hemoglobin (Hb) 14, electrolytes were within normal limits (WNL). BUN (blood urea nitrogen) /Creatinine 18/1.16.

The patient was initially thought to have community acquired pneumonia (CAP) so was started on Rocephin and Azithromycin.

The chest x-ray (CXR) did not reveal any acute infiltrate or pleural effusion.

The patient's V/S (vital signs) were repeated in a few hours: Temperature 98, Blood Pressure 108/71, Respiratory Rate 18, Heart Rate 98, and oxygen saturation was 95% on room air.

As per history and physical the (H&P) the patient was afebrile and hemodynamically (HD) stable. The patient's lungs were clear. Cardiovascular systems were normal. There was no edema. The diagnosis was atypical chest pain (CP).

The patient's D dimer (protein fragment) came back elevated to >3000. The brain natriuretic peptide (BNP) was within normal limits. An electrocardiogram (EKG) revealed sinus tachycardia with left Anterior Fascicular Block (LAFB). There were no acute ST-T (intervals on an EKG) changes.

The patient remained afebrile and hemodynamically (HD)stable. She was not hypoxic. A pulmonary computed tomography angiography (CTA) was ordered, and the patient was placed on anticoagulation. CTA revealed a small pulmonary embolism (PE) in the distal right main pulmonary artery (PA). There were no pulmonary infiltrates or effusions seen.

The patient was continued on oral Eliquis. There was no evidence of a right heart strain on the echocardiogram (ECHO) or EKG. 

The patient remained hemodynamically (HD) stable, was not hypoxic and was tolerating oral intake.
 
The patient was subsequently discharged home. 

This patient did not need acute inpatient hospitalization. She could have been placed in Observation status while diagnostic testing and treatment were initiated. Observation status could be for up to 48 hrs. The patient did not have a pneumonia or myocardial infarction (MI). The pulmonary embolism (PE) was small with no evidence of right heart strain.

The patient's vital signs were stable after a few hours of hospitalization.

She was awake, alert, tolerating oral (PO). Her O2 saturations were normal on room air. She could have been discharged after a period in observation on PO Eliquis and PO antibiotics if clinically indicated with a close follow up as an outpatient. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the hospital admission is upheld. Medical Necessity is not substantiated.