Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypotension
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay. 
The denial is upheld.

The patient is a male with a past medical history significant for hypertension, hyperlipidemia, prediabetes, and heart failure with reduced ejection fraction, who presented to the hospital with complaints of blurred vision. This episode was transient. He reported having similar episodes a few months before his presentation.

He was at home watching television with his friends when suddenly he started to experience blurry vision and a sensation of heaviness in both shoulders. The blurriness resolved on its own. However, Emergency Medical Services (EMS) was dispatched, and the patient was brought to the emergency department.

The review of systems was negative for chest pain, shortness of breath, diaphoresis, palpitations, dizziness, vertigo, and lightheadedness. Otherwise, the patient reported being in his usual state of health. He specifically denied orthopnea, paroxysmal nocturnal dyspnea, edema, and dyspnea on exertion.

Upon initial evaluation in the emergency department, the patient was afebrile. Pulse rate was 85 beats per minute (bpm), respiratory rate 18 breaths/minute, blood pressure 88/63, oxygen saturation 95% (percent) on room air. Two hours later his blood pressure went up to 116/81.

He appeared to be in no acute distress. 

The patient was admitted to the hospital with a diagnosis of hypotension, blurred vision, pre-syncope, hyperlipidemia, and type II myocardial infarction most likely due to demand ischemia, and acute decompensated congestive heart failure (CHF).

The patient was treated with diuretics. Beta-blockers and valsartan were placed on hold due to initial hypertension. The patient tested positive for coronavirus 2019 (COVID-19) infection, however, he was completely asymptomatic and did not require oxygen. Another clinical problem was acute kidney injury. Urine electrolytes were ordered.

The subject under review is the medical necessity for the inpatient hospital stay.

There are no clear indications for admission at the acute inpatient level of care, since there were no signs of hemodynamic instability or severe or persistent altered mental status. The initial hypotension that was diagnosed in the emergency department resolved within the first couple of hours. There was no indication that the possible presyncopal episode was related to pulmonary embolism, arterial dissection, acute blood loss anemia, or acute coronary syndrome.

Even though it was suspected that the patient had mild acute CHF exacerbation, there was no clinical evidence that the patient had respiratory symptoms and hypoxemia consistent with mild CHF seen on the chest x-ray. There were no clinical signs of significant volume overload. Based on the telemetry monitoring, there was no evidence that the patient had a high degree of atrioventricular block, bradycardia with sinus pauses, and bursts of supraventricular tachycardia. Furthermore, there was no evidence that the patient was severely dehydrated.

His kidney function improved overnight. The elevation of creatinine was likely related to the use of angiotensin II receptor blockers (ARB). Elevated troponin was likely related to abnormal kidney function and did not represent true acute coronary syndrome.

Even though the patient tested positive for COVID 19, he remained essentially asymptomatic and did not need any treatment.

The review of the medical records revealed that the patient remained in stable clinical condition during the entire hospital stay and did not require any treatment or testing that would justify admission at the acute inpatient level of care. The patient could have been managed safely at a lower level of care status.