Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Respiratory System.
Treatment:  Inpatient Hospital.

The insurer denied the Inpatient stay.  The denial is upheld in whole.

The patient is a female with a past medical history significant for hypertension, hyperlipidemia, and microscopic anemia, who presented to the emergency department with complaints of palpitations, which had been going on for one month.  Reportedly, the patient was in her usual state of health when she took a flight to Guyana.  Upon arrival, there she started to have episodes of dizziness, anxiety, shortness of breath, and palpitations.  She also noticed weight loss.  Because of her symptoms, she decided to interrupt her vacation and came back to the U.S.

Laboratory evaluation revealed that her sodium was 138, potassium 4.3, chloride 101, bicarbonate 23, blood urea nitrogen (BUN) 20, creatinine 1.27.  Troponin was normal.  White blood cell count was 8.52, hemoglobin 10.2, hematocrit 32.8. Computed tomography (CT) angiogram of the chest revealed small right lower lobe pulmonary embolism.

The patient was admitted to the hospital and received treatment with Lovenox injection.  Subsequently, the patient was transitioned to oral anticoagulation with Eliquis.  During the hospital stay the patient received treatment with intravenous fluids, and she was monitored on the telemetry floor.  Since the patient remained in a stable clinical condition, she was discharged from the hospital.

The health plan's determination is upheld in whole.

The inpatient stay was not medically necessary.  To assess the severity of the patient's condition, the Pulmonary Embolism Severity Index (PESI) was utilized.  This is a risk stratification tool that predicts the 30-day outcome of patients with pulmonary embolism using 11 clinical criteria.

Based on the calculations, the patient received 90 points, therefore she belonged to Class III.  This means that the patient had an intermediate risk: 3.2-7.1% 30-day mortality in this group.  Therefore, the patient should have been admitted to the hospital for further observation and treatment, which in this clinical case included initiation of anticoagulation.

According to the Merck Manual Professional Version online, "Most patients with PE should be hospitalized for at least 24 to 48 hours.  Patients with abnormal vital signs or massive or submassive pulmonary embolism (PE) require longer periods of hospitalization."

In this case, the patient had a small PE; she remained afebrile and hemodynamically stable.  There were no alarming features during the period of observation.  The patient was successfully started on anticoagulation and was discharged home the very next day after the day of admission.

Taking into consideration these facts, monitoring the patient was definitely indicated to ensure hemodynamic stability and the patient's tolerance of anticoagulation.  Having said that, neither the severity of the patient's condition nor the complexity of the services provided rose to the level of acute inpatient care.

Overall, the hospital admission was short, and the patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.