Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthostatic hypotension

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission. The denial was upheld.

This patient is a female with a history that included anemia and asthma, who presented to the ED with a complaint of dizziness. Vital signs were not listed on the ED notes. Per the ED note of date of admission; the patient had an abdominoplasty and breast surgery the day before presenting. Since the surgery she had been dizzy, sweaty, and having palpitation whenever she tried to get up. She received IV fluids with no improvement in symptoms; no fever. The patient was having pain at the surgical sites as well as a headache now. On exam she was in no apparent distress. Exam was essentially unremarkable. She was given IV fluid and was still orthostatic after IV fluid and packed red blood cells (PRBC).

The patient was admitted for orthostatic hypotension. As per the history and physical (H & P) the patient has been tachycardic and orthostatic. No hypoxia was noted with her oxygen maintained at 99%. She was transfused and the tachycardia did not improve. The pre-operative Hct was 37, as per the patient. The patient denied chest pain and had mild shortness of breath (SOB). She had received 2 units of PRBC. The H&P noted that orthostasis and tachycardia was likely due to anemia. The patient had a TTE doppler of the heart which was grossly normal. Chest x-ray was normal.

Critical care saw the patient and noted that the patient was tachycardic and had orthostasis and noted that the BP ranged from 107/63 to 123/81 and was currently 107/63. The patient was postop from extensive plastic surgery and had significant anemia with orthostatic hypotension due to blood loss. The patient has mild asthma and probable atelectasis. The BP and tachycardia improved with fluids and transfusion. Abnormal EKG of uncertain etiology and Cardiology was called. Cardiology saw the patient and noted that pre-syncope was likely due to hypovolemia and orthostatic hypotension and that EKG abnormalities were likely patient's baseline and that given duration of symptoms, acute myocardial infarction (MI) ruled out with one set of cardiac enzymes. The echo was normal, and the plan was to monitor the patient overnight.

According to MCG health General Recovery Care 23rd Edition General Admission Criteria GRG: CG-GAC (ISC GRG) admission is indicated for 1 or more of the following: Hemodynamic instability; Hypertension requiring inpatient treatment; Acute cardiac or peripheral ischemia; Cardiac arrhythmias of immediate concern; Severe heart failure; Respiratory abnormalities; Severe airflow or ventilation abnormalities; Impending or actual respiratory arrest; Neurologic abnormalities; New-onset severe neurologic findings; Suspected acute intra-abdominal process; Severe physiologic disorder; Abdominal abnormalities; Severe behavioral health issues; Inpatient monitoring needed; Treatment requiring inpatient care; Emergency procedures needed. 

Based upon the records provided the inpatient hospital admission was not justified at the acute care level as the patient could have been managed in an observation setting and did not require an acute care admission. As shown in the chart the patient was tachycardic, but this was due to blood loss from her surgery and that with transfusion her vital signs improved. Her dizziness was clearly due to the acute blood loss from surgery and that she was not fluid resuscitated during her prior surgery.  

This patient did not have any indication for admission based upon the above criteria as she could have been placed on observation with her orthostasis and could have been corrected with IV fluids and blood transfusion. She did not have hemodynamic instability but rather had volume depletion from her surgery and that with proper fluid resuscitation she was stable. By the following morning her heart rate was down to normal, her BP was improved, and the Cardiologist did not find any significant abnormality. Thus, observation care was all that was needed.

The health care plan did act reasonably and with sound medical judgment and in the best interest of this patient. 

Based on the above, the medical necessity for the inpatient hospital admission 
is not substantiated.  The insurer's denial is upheld.