Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dyspnea. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Hospital Stay. 
The determination is upheld. 

The patient has a history of hypertension (HTN), hyperlipidemia, coronary artery disease (CAD), heart failure with reduced ejection fraction (HFrEF), chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD), prior ethyl alcohol (ETOH) withdrawal seizures who presented with 3 days of chest pain and dyspnea after using cocaine and non-compliance with diuretics and inhalers. 
In the emergency department (ED), his temperature was 97.5 degrees Fahrenheit, blood pressure (BP) 144/89, heart rate (HR) 79, respiratory rate (RR) 19, and peripheral capillary oxygen saturation (SpO2) 100% on room air (RA). He was ill appearing and diaphoretic, heart was regular, breathing was tachypneic but had no accessory use or distress, wheezy, alert and oriented. The white blood cell count (WBC) was 9.28, sodium (Na) 140, bicarbonate 22, blood urea nitrogen (BUN) / creatinine (Cr) 20/1.75, troponin (Tn) 0.034. An electrocardiogram (ECG) had no ischemic changes. A chest x-ray (CXR) showed pulmonary edema. The patient received nitroglycerin, aspirin, and furosemide and did feel better after. The peak flow was 150 liters per minute (L/min), after nebulizer, the peak flow was 250L/min. 

The patient was admitted and diagnosed with shortness of breath (SOB) felt to be from either congestive heart failure (CHF) or chronic obstructive pulmonary disease (COPD) and was started on his home oral furosemide dose and Duonebs, and a repeat Tn was ordered. 

He was doing well, was comfortable, saturating well on room air (RA), and the heart failure with reduced ejection fraction (HFrEF) was felt to then be compensated and at baseline, on oral diuretics, and it was felt that he would be ready for discharge in the next 24 hours. The repeat Tn was improved. 

He had an episode of syncope, felt to be from dehydration, and was given gentle hydration. He continued to do well, had no symptoms, and was discharged home. 

At issue is the medical necessity of an inpatient stay. 

The inpatient stay was not medically necessary. 

The patient presented with chest pain and dyspnea but was not severely ill with no encephalopathy, hemodynamic instability, respiratory distress or gas exchange abnormality. He had a mild acute kidney injury (AKI) that improved with observation care and in the progress notes was not actively addressed (no diagnostic or therapeutic regimen). He was diagnosed with either CHF or a COPD flare, but the only active treatment he received was intravenous (IV) furosemide in the ED. He was already converted to an oral regimen. Routine scoring systems would suggest a low risk of worsening. A COPD flare was also considered, and scoring systems would suggest his risk of worsening from this was also low, and he received only nebulized bronchodilators, no systemic steroids or antibiotics. He did have chest pain but no significant electrocardiogram (ECG) changes, a repeat Tn was improved, and the team was not concerned for acute coronary syndrome (ACS). 

He did experience syncope, but this was not felt to be from ACS, arrhythmia, pulmonary embolism (PE), or other concerning diagnosis. The symptoms resolved and did not recur.
Given the low severity of illness, rapid resolution (symptoms resolved by the next day), and low risk of worsening, he did not need inpatient only testing, monitoring, or treatment or a prolonged admission. Care could have been provided at a lower level.