Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System
Treatment: Inpatient Hospital
The insurer denied: Inpatient stay
The denial is: Upheld in whole

The patient is a female with a past medical history significant for diabetes, chronic venous stasis, obesity, hypertension, gastroesophageal reflux disease (GERD), and hyperlipidemia who presented to the emergency department with complaints of shortness of breath at the recommendation of her pulmonologist.
Reportedly, the patient's shortness of breath was going on for several months before admission.
In fact, she was admitted to the hospital recently. Following the discharge, the patient was prescribed a Prednisone taper that largely provided relief of shortness of breath. Reportedly, since the patient finished the Prednisone taper, her shortness of breath recurred.
At the time of initial evaluation, she complained of generalized chest discomfort but denied cough, fever, chills, nausea, vomiting, diarrhea, skin rash, or changes in bowel movements.
On the initial assessment, the patient was afebrile, respiratory rate was 25/min, however within one hour it came down to 19/min. Blood pressure was 153/64, oxygen saturation was 95-97% on room air.
The patient appeared to be alert, in no acute distress. The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. The neck was supple without lymphadenopathy, masses, JVD, carotid bruits. Lungs were clear to auscultation without wheezing, rales, or rhonchi. The patient had a regular rate and rhythm, without murmurs, rubs, or gallops.
The rest of the physical exam was unremarkable.
Laboratory evaluation revealed that pH was 7.47, partial pressure of carbon dioxide (pCO2) 38, partial pressure of oxygen (PaO2) 61, bicarbonate 29.
The urinalysis was positive for a trace of leukocyte esterase, 5-10 white blood cells. White blood cell count was 10.7, hemoglobin 10.9, hematocrit 33.8, platelets 255. D-dimer was elevated at 370.
A chest x-ray revealed mild right basal pulmonary infiltrate consistent with pneumonitis.
Computed tomography (CT) angiogram of the chest showed no evidence of acute pulmonary embolism.
During the hospital stay, the patient received treatment with Solu-Medrol, Lasix. Reportedly, she was seen by a pulmonologist and a cardiologist.
During the entire hospital stay, the patient remained in stable clinical condition and was discharged from the hospital.
The subject under review is the medical necessity for the inpatient stay.

The inpatient stay was not medically necessary for this patient.
At the time of the initial evaluation and during the entire hospital stay, this patient remained afebrile and hemodynamically stable. There were no signs of respiratory distress. The patient had a normal respiratory rate and oxygen saturation.
There was no evidence that the patient's symptoms were related to acute coronary syndrome or arrhythmia of immediate concern.
There was no need for invasive or noninvasive mechanical ventilation.
CT scan of the chest did not demonstrate any acute abnormalities necessitating admission at the acute inpatient level of care.
There was no evidence that the patient had any concomitant unstable condition which would justify admission at the acute inpatient level of care.
Taking into consideration all these facts, while an inpatient stay was not medically necessary it was appropriate to monitor the patient to look for the reason for the patient's symptoms. This could have been completed at a  lower level of care status.
However, according to the accepted standards of care, neither the severity of the patient's condition nor the complexity of the services provided rose to the acute inpatient level of care.