Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of Breath. 
Treatment: Inpatient Hospital Stay. 
The insurer denied the Inpatient Hospital Stay. 
The determination is upheld. 

This patient with a family history significant for mitral valve prolapse, personal history of gastroesophageal reflux disease (GERD), and tobacco use disorder who presented to the emergency department with complaints of dyspnea on exertion that became worse over the prior 2 days. He started to experience shortness of breath approximately 3 weeks before the presentation after going out of town. While riding on a bus, the patient started to experience shortness of breath unrelated to exertion. At the time of admission, the patient stated that he had been vaping for two years but when his symptoms started, he stopped vaping since he thought that the shortness of breath could be related to that. He also stated that ever since he got back from his trip out of town, he has been using 2 pillows to sleep and had occasional paroxysmal nocturnal dyspnea. 
Upon initial evaluation in the emergency department, he was found to be normotensive. The physical exam was unremarkable. Initial laboratory evaluation was also unremarkable. An electrocardiogram (EKG) showed normal sinus rhythm. Based on the patient's symptoms, he was admitted to the telemetry floor for further evaluation. 
Serial troponins were ordered and remained negative. The laboratory evaluation included a fasting lipid profile, which was normal. The D-dimer was 0.35. The chest x-ray showed no evidence of consolidation. During the hospital stay, the patient was ruled out for a deep vein thrombosis (DVT) and pulmonary embolism as well as an acute coronary syndrome. 
The echocardiogram revealed that the interior valve leaflet was mildly redundant without significant prolapse. The posterior leaflet appeared normal. The patient had minimal mitral valve regurgitation; normal left ventricular wall motion and ejection fraction. 
The telemetry monitoring showed no evidence of arrhythmias. The patient was suspected to have obstructive sleep apnea that manifested in mild hypercapnia. 
During the hospital stay, the patient remained afebrile and hemodynamically stable. While in the hospital there were no complaints of chest pain, shortness of breath, or palpitations. 
He was discharged home in stable clinical condition, with recommendations for outpatient polysomnography, and outpatient consultation with a pulmonologist. At issue is the medical necessity of an inpatient stay. 

The inpatient stay was not medically necessary. The patient was admitted to the hospital for evaluation of shortness of breath and chest tightness. However, the extensive evaluation did not demonstrate any serious reasons for his symptoms. He was ruled out for acute coronary syndrome and pulmonary embolism. There was no evidence of aortic dissection or aneurysm. His carbon dioxide (CO2) retention was possibly related to obstructive sleep apnea but was not associated with altered mental status or any other conditions requiring admission at the acute inpatient level of care. Overall, he remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. Care could have been provided at a lower level. 

This coincides with Milliman Care Guidelines (MCG) 23rd Edition Pulmonary Disease General Recovery Guidelines (GRG). The patient did not meet the criteria for acute inpatient admission. Specifically, based on the arterial blood gas (ABG), there was no evidence of respiratory acidosis, and the partial pressure of carbon dioxide (pCO2) was only slightly elevated above the normal range.