Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Intermittent chest pain and shortness of breath (SOB) for 2 days
Treatment: Inpatient Stay
The insurer denied the inpatient stay.
The health plan's determination is upheld.

The patient is a female who presented to the emergency department (ED) with complaints of bilateral lower extremity heaviness and shortness of breath for the last few days. The patient was noted to have a normal blood pressure and a normal pulse. An electrocardiogram (EKG) was performed which was notable for ventricular repolarization (T wave) inversions. The patient is noted to have a history of stage IV uterine papillary serous carcinoma and is receiving chemotherapy. Her last dose of chemotherapy was approximately one week prior to presentation to the ED. Her chest x-ray noted no focal consolidation.
The patient's laboratory studies included a white blood cell count of 2.8, a hemoglobin of 8.1, a platelet count of 403, a sodium of 128, a potassium of 2.9 and a chloride of 97. Her past medical history is remarkable for hypertension and the only medication she takes is Atenolol. Her history is notable for a diagnosis of papillary serous carcinoma from a necrotic cervical mass several months ago and it appears that she was being treated with neoadjuvant chemotherapy. The plan upon admission was for Potassium and Magnesium repletion as well as maintenance intravenous (IV) fluids.
The patient was seen on rounds and denied any chest pain or shortness of breath. It was noted that she was still in the emergency department at that time. She was hemodynamically stable. She was noted to have neuropathy. Her sodium improved and her potassium improved to 4.2. When she was seen later in the day, it was again noted that her EKG showed significant T wave improvement, however her hemoglobin was noted to have dropped to 7.4. The patient received a transfusion of 1 unit of Packed Red Blood Cells (PRBC's). The patient's magnesium was also noted to be normal when checked and it was 2.1 milligrams per deciliter (mg/dL).
A discharge summary was drafted indicating that the patient was admitted for chest pain and dyspnea. The patient was noted to have negative troponins and a repeat EKG was noted to show resolution of her T wave abnormalities. The patient's computed tomography (CT) angiogram was negative for pulmonary embolism. The patient had a walking test and her oxygen saturations remained acceptable. Upon discharge, the patient's potassium level was normal. 

The health plan in its determination of medical necessity acted reasonably and with sound medical judgment and in the best interest of the patient. The patient has an advanced uterine cancer for which she was receiving chemotherapy when she presented to the ED with complaints of shortness of breath and chest pain. All imaging was essentially normal and the only derangements noted were T wave inversions on her EKG, hyponatremia, hypokalemia and hypomagnesemia. 

The patient received electrolyte repletion as well as a blood transfusion. In general, this can be accomplished at an alternate level of care and does not require an admission to the hospital. The patient was admitted due to her complaints of her difficulty with ambulation. This completely resolved upon addressing her electrolyte abnormalities and her ensuing anemia. The documentation implies that the patient spent a substantial portion of her stay in the emergency department awaiting an inpatient room.