Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dyspnea, decreased exercise tolerance.
Treatment: Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

The patient presented to the emergency department complaining of exertional dyspnea, body aches, chills and anorexia. She had not eaten in four days. Her medical history was remarkable for hypertension, diabetes and chronic kidney disease with a baseline serum creatinine level of 2 milligrams per deciliter (mg/dl). Her blood pressure was 164/80 millimeters of mercury (mmHg) with a heart rate of 89 beats/minute. Her respiratory rate was 20/minute with a room air oxygen saturation of 98%. She was afebrile. Her physical exam was unremarkable. An electrocardiogram showed sinus rhythm without acute changes. Her serum troponin level was less than (<) .01 nanograms/milliliter (ng/ml) and rose to .04 ng/ml when repeated. She had an anion gap acidosis. Her venous potential of hydrogen (pH) was 7.25; her anion gap was 26. Her blood urea nitrogen (BUN) was 39 with a creatinine of 2.77 mg/dl. Her serum potassium level was normal. Testing for influenza and coronavirus disease 2019 (COVID-19) was negative. Her blood glucose level was 54 milligrams per deciliter. Her lactate level and white blood cell count were normal. An echocardiogram showed normal left ventricular systolic function and no pericardial effusion. A renal ultrasound showed chronic kidney disease. The patient was treated with intravenous fluids and Dextrose and admitted to the hospital. She was seen by a cardiologist who opined that there was no evidence of acute coronary syndrome and attributed her troponin elevation to her renal disease. A third troponin level was < .01 ng/dl. Her previously prescribed metformin was stopped. The patient's anion gap was 17. Her creatinine level was 2.84 mg/dl and her blood glucose was 142 mg/dl. She was discharged. The medical necessity of an inpatient admission is at issue.

No. An inpatient level of care was not medically necessary.

This patient, with multiple cardiac risk factors, presented with dyspnea and had a minimally elevated troponin level. Based on the troponin level, there was concern for acute coronary syndrome (ACS). Accordingly, observation until ACS could be ruled out was a reasonable approach. However, she was hemodynamically stable, with no ischemic electrocardiographic changes. She did not require intensive monitoring, acute intervention or infusion of intravenous cardioactive medications. Her elevated troponin level was attributed to her kidney disease. The care this patient received for her dyspnea and elevated troponin level did not require an inpatient admission and could have been provided at a lower level of care. This approach has been shown to be safe and is in accordance with the 2014 American Heart Association (AHA) / American College of Cardiology (ACC) Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.

The patient also had evidence of acute on chronic kidney disease with anion gap acidosis. The records provided do not address what the presumed etiology was but her acidosis and creatinine level improved with intravenous hydration. The patient was not hyperkalemic or hypermagnesemic. She had no pericardial effusion. She was not volume overloaded and did not require renal dialysis. While hospitalization for hydration and monitoring of her laboratory values was medically necessary, this could have been accomplished at a lower level of care than inpatient. The health plan's determination of medical necessity is upheld.