Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Dyspnea.
Treatment:  Inpatient admission.
The insurer denied the inpatient admission.  The denial is upheld.

Inpatient level of care was not medically necessary.

This female presented with dyspnea, progressive over the last three days, and fatigue.  She was non-compliant with her medications including prescribed diuretics.  Multiple co-morbidities including obesity, pulmonary emboli history, congestive heart failure (CHF), automatic implantable cardioverter defibrillator (AICD), lymphoma history, and hypertension. 

Initial exam showed tachypnea, tachycardia, wheezes, pitting edema, and possible renal insufficiency.  Diagnoses were pneumonia and CHF.  The patient was treated with diuresis and antibiotics.  Her left ventricular ejection fraction (LVEF) was 16% and brain natriuretic peptide (BNP) was 3561.  Oxygen saturation on room air was normal with range 93% to 100%.  Heart rate was in the 70's.  The patient was discharged on oral medications after a two-night hospital stay. 

This patient had a known cardiomyopathy and was noted to be non-compliant with her medications.  The patient was admitted for diuresis, which was done initially with intravenous (IV) Bumex and antibiotics.  She responded and was discharged back on her usual meds after two nights.  There was no evidence of a myocardial infarct (MI), and she was clinically stable throughout course with no requirement for supplemental oxygen, as oxygen (O2) saturations were always above 93% and reached 100%.  Vital signs were stable, and labs improved. 

The determination of level of care is primarily dependent on the actual care a patient receives and, whether a higher level of acuity is needed to give this care.  This is best reflected in the presentation, physical exam findings, and laboratory orders and their results; and highlighted in the orders for care. 

In this case, the symptoms were unlikely to be representative of acute coronary syndrome.  Her history was well documented, not changed.  Exam was normal, except for expected abnormal breath sounds, and cardiac findings were normal.  Biomarkers and electrocardiogram (EKG) showed no evidence of acute ischemia.  Chest x-ray (CXR) was consistent with CHF.  Echocardiogram showed known wall motion abnormality and low EF.  The physicians' treatment did not reflect any serious concern about patient's cardiac condition having progressed.  Orders did not include medical therapy for acute coronary syndrome (ACS), such as IV heparin, dual antiplatelet inhibitors, high dose beta blockers or IV nitroglycerin (NTG).  Treatment did not include pulmonary artery (PA) monitoring or need for advanced care. 

The letter of appeal was carefully considered but offered no evidence to support inpatient level of care.  There was no evidence to admit due to evidence by clinical or guideline standpoint.  The only cardiac care provided was telemetry, frequently performed in a lower level of care.  The patient was admitted for monitoring and subsequent tests, and therapy did not require an inpatient level of care.  There was no evidence to support the diagnosis of cardio renal syndrome.  There was no complex care that required inpatient care as basically, the patient restarted her medications after an aggressive diuresis.  This patient had no evidence of coronary artery disease (CAD).  While there is always a potential for an adverse event, one did not happen, and no actual unexpected treatment was added.

Milliman criteria requirements were not fulfilled, as there was never any evidence of ACS or cardio renal syndrome present.  Clinical indication of tachypnea is noted, but her oxygen saturations reached 100% on room air and were never lower than 93%.  Thus, there was no evidence of respiratory distress leading to hypoxia.  All testing and therapy would be appropriate, safe and guidelines consistent to be in lower level of care.  Thus, inpatient level of care was not medically necessary.