Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Shortness Of Breath.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a female whose Inpatient admission is under review.

The patient has a history of HTN (hypertension), right bundle branch block, asthma, chronic COPD (chronic obstructive pulmonary disease), OSA (obstructive sleep apnea) with CPAP/NIV (continuous positive airway pressure/non-invasive ventilation) and Home Oxygen 2L (two liters) via NC (nasal cannula) as needed, Pancreatitis, GERD (gastroesophageal reflux disease), Osteoarthritis, hernia repair, Class III morbid obesity with BMI (body mass index) of 61.1, status post TVH/BSO/LOA (Total Vaginal Hysterectomy/bilateral salpingo-oophorectomy/lysis of adhesions) for endometrial cancer, and Umbilical hernia repair with discharge to ED (emergency department) complaining of SOB (shortness of breath), dyspnea and palpitations. She was noted to have had fever a week before presenting. She was noted to have dyspnea and palpations x 1 day. She also had chills.

In the ED (emergency department), the patient's VS (vital signs) were as follows: T (temperature) 99.9 (maximum temperature 101.8), P (pulse) 113, RR (respiration rate) 32, BP (blood pressure) 179/85, Spo2 (blood oximetry) 96% on RA (room air).

The patient was noted to be diaphoretic, shaking, grunting, and in distress. Examination of her CVS (cardiovascular system) was notable for tachycardia. Examination of her chest was notable for shallow breath sounds. Examination of her GI (gastrointestinal system) was notable for NT/ND (non-tender/non-distended). The patient's Bipap mask was on. She had minimal bilateral wheeze, and she had labored breathing. There was bilateral LE (lower extremity) non-pitting edema present with chronic venous stasis changes.

The patient's CXR (chest x-ray) revealed stable cardiomegaly with congestive changes. Her EKG (electrocardiogram) revealed SR (sinus rhythm) at 97 bpm (beats per minute) with fusion complexes, right bundle branch block, and inferior infarct, age undetermined. Her CTA (Computed Tomographic Angiography) pulmonary revealed decreased bibasilar atelectasis, negative for PE (pulmonary embolism). CT (computed tomography) abdomen/pelvis revealed bilateral pelvic adenopathy, no hydronephrosis.

In the ED (emergency department), the patient was thought to have fever, sepsis, and respiratory distress in the setting of a recent surgery. She was started on IV (intravenous) vancomycin and Zosyn and admitted. While admitted, she was seen by Infectious Diseases, OB/GYN (obstetrics/gynecology), and pulmonary consult teams. She improved over the next few days without identifying a definite source of infection, and she was discharged home.

The health plan's prior denial was because the patient did not meet the criteria for sepsis, while the appeal was that the admission was supported by AMA (American Medical Assosiation) and Medicaid criteria for standard of care and medical necessity.

Yes, the Inpatient admission was medically necessary.
The patient meets a diagnosis of sepsis, with fever, tachycardia, and tachypnea (1). Given the obvious respiratory distress, the use of home oxygen at baseline and diminished respiratory reserve, many comorbidities, need for multiple consultants, and recent surgery, standard of care would require admission and inpatient treatment for such a patient. Failure to do so could lead to septic shock, organ dysfunction/failure, and death.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.