Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Myocardial infarction.
Treatment:  Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is overturned.
 
This is an elderly patient with a medical history that includes hypertension (HTN), hyperlipidemia (HLD), pulmonary hypertension (pHTN), heart failure with reduced ejection fraction (HFrEF) of 40-50% (percent), severe mitral regurgitation, asthma, chronic obstructive pulmonary disease (COPD), prior pulmonary embolism (PE) on apixaban, two prior strokes (CVA), and Alzheimer's dementia.

She presented to the emergency department (ED) after a fall in the shower at home. She had previously fallen out of bed and was also evaluated in the ED for that, approximately 48 hours earlier. She was unable to provide history, and family could not be reached; the ED evaluation indicated that the patient did not know if she had hit her head. There were multiple abnormalities noted in the ED workup, involving multiple organ systems. These included renal failure (acute on chronic), anemia, a heart murmur, and an elevated troponin T (high sensitivity) of 0.030 nanograms per milliliter (ng/mL). Chest x-ray, head computed tomography (CT), x-rays of the right knee and hips, and a CT of the abdomen and pelvis showed no alarming, acute findings. She was admitted specifically for renal failure, troponin elevation (with the ultimate presumptive diagnosis of Type II (2) MI (myocardial infarction) due to renal failure), and falls. There was also mention in the ED note that there was a concern regarding intracranial hemorrhage, despite negative head CT, with an infectious etiology also possible. A syncope workup was recommended.

A conservative approach was pursued; intervention appears to have focused on continuing her home meds (medications), hydrating her, treating her pain with acetaminophen, and following labs, which gradually improved somewhat but did not completely normalize. She was ultimately discharged to home after three midnights in the hospital. The discharge summary indicates that additional history could not be obtained, and a mechanical fall from bed was suspected (although this admission was for a fall in the shower).

At the time of her admission, her high sensitivity troponin level was consistent with myocardial infarction (MI), specifically a Type 2 MI, as no indication of active coronary thrombus was identified in this case. However, it appears that no such workup was pursued, for reasons that are not specified in the medical record. 

In the ED, initial concerns also included the possibility of an un-diagnosed intracranial process. The UpToDate pathway for evaluation of mild head trauma, at Step 4, asks the clinician to determine if there are "Criteria for Inpatient Observation," which appears to be the primary issue under question. Criteria supporting inpatient treatment include, "The patient has a bleeding diathesis or is taking anticoagulant medication (some clinicians would also observe individuals taking antiplatelet agents, particularly older adults)."

The inpatient hospitalization was medically necessary for the patient, for the reasons outlined in the first response. Specifically, she had two falls requiring hospital evaluation within 48 hours, and evidence of multiple organ system failure, including non-ST (interval on an ECG) elevation myocardial infarction (NSTEMI) and worsening renal failure. Additionally, there were concerns regarding possible head trauma.  These represent appropriate criteria for inpatient treatment at the time of admission, regardless of the extent of the subsequent workup.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an inpatient hospital admission is substantiated.