Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bilateral Lower Extremity (LE) Swelling.
Treatment hospital admission.
The insurer denied coverage for hospital admission.
The denial is upheld.

The patient presented to the hospital with complaints of bilateral lower extremity (LE) swelling and scrotal and penile edema. The patient had been recently in the hospital for same complaints. The patient had been treated for uncontrolled diabetes mellitus (DM) / diabetic ketoacidosis (DKA) during that admission in addition to anasarca.

The patient had been non-compliant with his meds post discharge. Vital signs at presentation Temperature 99, Blood Pressure 150/95 mmHg (millimeter of mercury), Heart Rate 91, Respiratory Rate 17, Oxygen (O2) saturations 100% (percent). The patient was in no acute distress, and was speaking full sentences. Review of systems (ROS): The patient denied chest pain (CP)/shortness of breath (SOB)/Palpitations/Dizziness/Cough/Fever/Chills.

The physical exam revealed some rales on lung exam. Bilateral penile and testicular edema and lower extremity (LE) edema were noted. The patient was alert, and oriented. The abdomen was soft, and non-tender. Neurology exam was unremarkable.

White blood cell count was 5.5K (thousand), electrolytes were within normal limits, blood urea nitrogen (BUN) / Creatinine 19/0.9, blood gas (BG) 392. (The patient was non-compliant with Insulin), BNP (brain natriuretic peptide) 40, Troponin <0.01. The patient received 20 mg (milligram) of Lasix intravenous (IV).

Repeat Exam in the emergency department (ED) Temperature 97.9, Heart Rate 87, Respiratory Rate 18, Blood Pressure 148/91, Oxygen (O2) saturations 98%. The patient was in no acute distress (NAD). There was no jugular venous distention.
Cardiovascular system (CVS) was normal. The abdomen was soft and non-tender, breath sounds were positive, lungs were clear, there was pedal edema and scrotal and penile edema. Recent deep vein thrombosis (DVT) study was negative. Echocardiogram revealed left ventricular ejection fraction 70%.  Chest x-ray revealed (CXR) no pulmonary edema; no congestive heart failure (CHF); no pleural effusions urinalysis no proteinuria serum protein electrophoresis (SPEP) within normal limits. Ultrasound (USG) of liver revealed no acute hepatic pathology.  The patient was admitted to hospital. The patient was afebrile and hemodynamically (HD) stable through his stay. Lungs were clear to auscultation as per the history and physical and was treated with oral Lasix 20 mg /day.

Their clinical impression was that the patient's edema was non-cardiac. The patient's edema improved with Lasix.  This patient was discharged home on oral Lasix with recommendations to follow up in the outpatient setting. This patient did not need acute inpatient hospitalization. He was stable to be kept in observation status while diagnostic testing and treatment were initiated. The patient remained stable after admission, was on oral Lasix and in NAD. The lungs were clear and he was not hypoxic. No other acute findings were noted other than edema of the lower extremity and scrotum.

The patient could have been placed in observation status (which could be for up to 48 hours) while diagnostic studies and treatment initiated. Once patient improved and on oral medications, he could have been discharged home with follow up in outpatient setting.

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.