Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: COPD; CAD
 
Treatment: Acute inpatient

The insurer denied coverage for acute inpatient. The denial is modified. 

This patient is a male with a  history of diabetes mellitus (DM), hypertension (HTN), coronary artery disease (CAD), status post myocardial infarction (MI), congestive heart failure (CHF), non-sustained ventricular tachycardia (NSVT), status post automatic implantable cardiac defibrillator (AICD), who presented to the Emergency Department (ED) with complaints of shortness of breath (SOB), cough and chest pain. The patient's vital signs at the ED presentation were: temperature (T) 98, respiratory rate (RR) 20, heart rate (HR) 102 and blood pressure (BP) 159/88.  Oxygen (O2) saturations were 96 % on O2.  The patient's exam revealed bibasilar crackles. The patient's lab showed: white blood cell (WBC) count of 10.7 K, hemoglobin (Hb) of 15, BUN/ Creatinine ratio of 13/1.3, troponin level of 0.04, BNP level of 5084, and lactate level of 3.2.  The patient's electrocardiogram (EKG) showed no acute ST-T Changes. The patient's chest x-ray showed left peripheral infiltrate.  The patient was admitted with a diagnosis of chronic obstructive pulmonary disease (COPD) exacerbation and coronary artery disease (CAD).  The patient was treated with beta-blocker, Lisinopril, and Lasix, as well as Rocephin and Azithromycin.

Given the patient's multiple medical problems and presentation with chronic obstructive pulmonary disease (COPD), community acquired pneumonia (CAP), and questionable congestive heart failure (CHF), the patient's elevated troponin and lactate levels warranted inpatient admission for the treatment of sepsis/pneumonia, COPD, CHF and elevated troponins to rule out acute coronary syndrome (ACS). During admission, the patient's condition was ruled out for myocardial infarction (MI); the patient was treated with cardiac medications, and antibiotics for possible pneumonia continued.  Based on the patient's blood culture result positive for gram-positive infection, patient's antibiotics were adjusted accordingly; the patient was continued on acute management.

However, by a specified date the patient's blood cultures were identified to be contaminant - Coagulase Negative Staph.  The patient was afebrile and hemodynamically (HD) stable.  On exam, the patient was alert and oriented, and was in no acute distress (NAD).  The patient's lactate levels had normalized; and patient's troponin level decreased to 0.01. The patient was tolerating oral intake, and was clinically stable for discharge. Thus, while inpatient admission was necessary for the patient on the dates of service specified, continued inpatient hospitalization from other dates of service specified was not medically necessary.

The insurer's determination is modified. Inpatient admission was medically necessary. However, continued inpatient hospitalization from dates of service specified was not medically necessary. 

The health plan acted reasonably and with sound medical judgment and in the best interest of the patient for specified dates but did not act in the best interests of the patient for other specified dates.

The carrier's denial of coverage for the acute inpatient stay is modified.