Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient stay. 
The denial is upheld. 

The patient is a female with a past medical history significant for hypertension and polycystic kidney disease who presented to the emergency department with complaints of chest pressure that was accompanied by lightheadedness and shortness of breath. 
The patient stated that in the last two months that preceded the day of admission she had been increasingly lightheaded and had been getting parietal headaches, which were sharp and not associated with nausea or photophobia. The patient denied any syncopal events. 
On the day of the presentation, the patient had a headache and lightheadedness that were worse than usual. At the same time, she suddenly started to experience chest discomfort that she described as pressure that was associated with dyspnea. 
The pain radiated down the right arm. The patient also had some stiffness in the right arm. She stated that she had a feeling like her hands became extremely cold, but she did not notice any color changes in the fingers. 
The patient laid down, hoping that her symptoms would resolve, but since there was no improvement, she came to the emergency department (ED). By the time the patient was seen by the admitting physician, the chest pressure resolved. 

The patient was admitted to the hospital with a diagnosis of chest pressure and shortness of breath. Another clinical diagnosis was headaches accompanied by undifferentiated sensations and lightheadedness. Other clinical diagnoses included Autosomal dominant polycystic kidney disease (ADPKD), abdominal pain, flank pain, and a history of hypertension. 
In the hospital, the patient was seen by a gastroenterologist who was consulted because of reported weight loss and constipation. The gastroenterologist recommended esophagogastroduodenoscopy (EGD) and initiation of treatment with proton pump inhibitors as well as a bowel regimen. Abdominal ultrasound was performed and demonstrated multiple hepatic and right renal cysts. The EGD was interpreted as normal. 

During the hospital stay the patient was also seen by a cardiologist, and according to their recommendation, she underwent an echocardiogram that demonstrated normal left ventricular ejection fraction with mild mitral regurgitation and mild tricuspid regurgitation. 
Due to complaints of right-sided headache and abnormal sensation on the right side, the patient was seen by a neurologist who diagnosed the patient with complex migraine versus vestibular migraine. The neurologist recommended initiation of treatment with Nortriptyline, magnesium oxide, and Ubrelvy. 
During the hospital stay, the patient was monitored on the telemetry floor and had no evidence of arrhythmia. Her cardiac markers remained normal. 
The patient's clinical condition improved. Therefore, she was transitioned to outpatient care. 

The inpatient hospital stay was not medically necessary for this patient at the acute inpatient level of care. There was no evidence that the patient had a myocardial infarction or unstable angina. The echocardiogram was unremarkable, and the patient was ruled out for acute coronary syndrome. 
The gastrointestinal symptoms were also nonspecific. Her abdominal exam was benign and revealed no peritoneal signs. There was no mention that the patient had evidence of bowel obstruction or mesenteric ischemia. Her abdominal discomfort was most likely related to polycystic kidney disease. There was no evidence that the patient had severe dysphagia, gastroparesis, intractable diarrhea, or any other severe gastrointestinal symptoms that would justify admission at the acute inpatient level of care.