Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypotension. 
Treatment: Full hospital admission. 
The insurer denied the full hospital admission. 
The determination is upheld. 

The patient is a female who initially presented to the emergency department with concerns for hypotension. The pertinent history included rheumatoid arthritis, hypertension, sick sinus syndrome (SSS) status/post (s/p) permanent pacemaker (PPM), transient ischemic attack (TIA) on dual antiplatelet therapy, and asthma. A computed tomography (CT) scan of the head was unremarkable. The patient was admitted to the hospital with an impression of episodic symptomatic hypotension. The treatment plan included additional laboratory testing, orthostatic vital signs, and consultations. Neurology consulted and had an impression of chronic left lower extremity weakness, cognitive impairment, and hypotension. No further diagnostic testing was recommended. Endocrinology consulted and ruled out adrenal insufficiency. A chest x-ray (CXR) was suggestive of pneumonia. Antibiotics were empirically initiated for possible pneumonia. She had a recurrent fever of 101.1 degrees Fahrenheit. The WBC (white blood cell) was 7.4. Empiric antibiotics were continued. A CT scan of the chest was without evidence of pneumonia and antibiotics were discontinued. The patient was discharged. At issue is the medical necessity of an inpatient stay. 
Based on the clinical documentation provided, evidence-based literature and standards of care, acute inpatient level of care was not medically necessary for the entire admission. Evaluation and management could have been performed at a lower level of care.
The patient had a history of asthma and hypertension who was directed to the emergency department for concerns of hypotension seen at a clinic. Initial examination documented the patient as afebrile, alert, oriented, hemodynamically stable, and without hypoxia. Initial evaluation including laboratory testing, electrocardiography, and radiography was relatively unremarkable. Treatment plan included additional diagnostic testing, monitoring, and consultations. Neurology consulted and ruled out a need for additional neurologic tests. Endocrinology consulted and ruled out adrenal insufficiency. Following observation care, hemodynamics were stable and clinical improvement was documented. The hospital course was prolonged due to a fever. This was initially felt to be pneumonia; however, a computed tomography (CT) scan of the chest did not reveal any findings suggestive of pneumonia and antibiotics were discontinued. No other issues or complications were documented. 
Clinical indications for admission to inpatient care were not met. The patient did not have hypoxemia (partial pressure of oxygen (pO2)less than (<) 60 millimeters of mercury (mmHg) or oxygen saturation (SaO2) < 90 percent (%)), hemodynamic instability, severe or persistent altered mental status, severe or persistent dehydration, ventilator assistance needed, bacteremia, CURB-65 [(confusion, uremia, respiratory rate, BP {blood pressure}, age greater than or equal to ( >=) 65 years)] score of 3 or greater, Pneumonia Severity Index (PSI) class IV or V, CURB-65 score of 2 who did not improve with observation care treatment, outpatient treatment failure, appropriate diagnostic testing and treatment unavailable in outpatient or recovery facility, respiratory findings (eg, tachypnea) that do not respond to observation care treatment, complicated pleural effusions (eg, empyema, exudative, loculated), immunocompromised patient, or insolation indicated that cannot be performed outside hospital setting.[2]