Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pulmonary embolism 

Treatment: Inpatient admission

The insurer is denied coverage for inpatient admission.

The denial is upheld. 

This case involves then a female who was taken to the Emergency Department (ED) via ambulance for complaints of weakness as well as dizziness, vomiting, nausea and a fall.  The patient's past medical history included diabetes as well as asthma, anemia, and renal insufficiency.  Upon arrival to the ED, the patient's vital signs revealed a temperature of 97.6, pulse of 100, and blood pressure of 140/80.  The documentation also detailed the patient had complaints of pain to the left knee and ankle.  On exam, the patient was in moderate distress, but was otherwise unremarkable. The patient was alert and oriented. It was also recommended to hydrate the patient and give Zofran for nausea.  The patient's laboratory studies revealed a hematocrit level of 29.8 with hemoglobin of 9.7.  The patient's osmolality was 317.  The patient's d-dimer was elevated at greater than 18,000.  The patient's urine was positive for white blood cells.  The physician indicated that the patient continued to have complaints of shortness of breath when walking which was associated with lightheadedness.  Given the elevated d-dimer, coronary tomography angiogram (CTA) was recommended to rule out pulmonary embolism. However, due to this patient's renal insufficiency, CTA was deferred and the patient was treated empirically for pulmonary embolism. The patient was admitted to Medicine for further management.  

The patient continued with treatment and medication.  The patient underwent V/Q scanning which showed no evidence of pulmonary embolism.  The patient further underwent a computed tomography (CT) scan of the head, which showed no evidence of acute intracranial pathology; there was an old lacunar infarct to the left lentiform nucleus.  The patient also underwent an echocardiogram, which showed an ejection fraction of 60-65%.  Throughout the hospital stay, the patient's laboratory studies were trended. The patient continued treatment and was consulted by nephrology who recommended that the patient continue with intravenous fluids.  It was also recommended upon discharge that the patient follow-up with the renal clinic in the outpatient setting.  There were no significant adverse events during the hospital stay.  The patient was clinically stable for discharge.

The patient developed a weakness with dizziness without evidence of pulmonary embolism (PE) or acute stroke.  According to the submitted records, there is no clear evidence of acute change in the patient neurological examination.  No acute motor, sensory or visual deficit that suggest an acute stroke.  There is no instability, new focal neurological signs, acute stroke, hemodynamic or cardiovascular compromise or acute prolonged metabolic decompensation or seizure.   Therefore, the patient condition did not fulfill for acute inpatient care admission according to the referenced literature as there must be evidence of the above referenced conditions.  As such, the requested inpatient admission was not medically necessary as she could have been treated at a lower level of care.

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient admission should be upheld.  The medical necessity is not substantiated.