Appeal type: Medical necessity
Decision: Upheld

Diagnosis: End stage renal disease on hemodialysis

Treatment: Inpatient hospital admission

The insurer denied coverage for the Inpatient hospital admission.

The denial is upheld. 

This is a male patient who presented to the Emergency Department (ED) with a chief complaint of dizziness, nausea and near syncope. The patient has a medical history which includes hypertension, diabetes mellitus type II, end stage renal disease (ESRD)  on hemodialysis, coronary artery disease (CAD) with percutaneous coronary intervention (PCI), pontine hemorrhage and benign prostatic hypertrophy (BPH). The patient states that he finished dialysis on the day of ED arrival at 8a.m. and at approximately 2 p.m., he went to the laundromat. While there, the patient reported that he suddenly felt very weak, fatigued, and diaphoretic, and had an episode of near syncope. 

On arrival to the ED, the patient states that he still felt weak but had no other symptoms.  On physical examination, there were no abnormalities documented. A note written in the ED states that since the patient felt very weak/fatigue, the decision was to admit the patient for his near syncopal episode. The patient's pro- brain natriuretic peptide (BNP) level was greater than 45,000 and was correlated with pulmonary vascular congestion noted on his chest X-ray. The patient's head computed tomography (CT) scan without contrast showed that there was age-related cortical atrophy and white matter disease, and an old left basal ganglia infarct; there was a right parietal lobe calcification with no significant change from a previous study. The final impression was no acute cerebral pathology. The patient's chest X-ray showed cardiomegaly with pulmonary vascular congestion, with no pulmonary infiltrate and no pleural effusion. The patient's pro-BNP was 45,116. The patient's troponin was 0.266, and his glucose was 41. 

Dizziness is a common presenting concern in primary care practice and patients presenting to the ED. The most useful diagnostic approach in distinguishing different types of dizziness is a thorough history and physical examination; additional tests are rarely necessary. Effective treatments exist for many causes of dizziness and these treatments are often accomplished in the clinic or at home without the need for medication (Molner and McGee, 2014). Acute stroke is a serious concern in ED dizziness presentations. Prior studies, however, suggest that stroke is actually an unlikely cause of these presentations (Kerber et al., 2014). 

As per Wiler et al. (2011), multiple observation protocols have been developed which have been shown to be safe and deliver effective care. Thus, studies report that over one third of hospitals now have implemented an ED observation unit. In this case, this patient presented to the ED complaining of dizziness nausea and near syncope. The patient has diabetes mellitus and ESRD requiring dialysis. The patient is known to have CAD and had PCI several years ago. The patient's BNP level was very high and his troponin was elevated, which was not unexpected in this patient who was on dialysis. The most striking abnormality found in this patient's workup was a glucose level on admission of 41, which correlated with his symptoms. The patient had a complete neurologic workup and the neurologic consultant concluded that his symptoms were caused by hypoglycemia. The brief period of monitoring and treatment that this patient required did not require inpatient acute level of care and could have been accomplished in a less intense setting, such as the Observation status. Thus, inpatient hospital admission was not medically necessary for this patient.

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

The carrier's denial of coverage for the inpatient hospital admission should be upheld. The medical necessity is not substantiated.