Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female who presented to emergency room (ER). The patient was seen for complaints of dizziness. She received a phone call to come back to the hospital for treatment of blood culture and so she presented to emergency room. The patient's past medical history was significant for hypertension (HTN), diabetes mellitus (DM), and morbid obesity. Medications included Carvedilol losartan, hydrochlorothiazide (HCTZ), amlodipine, Lasix, Humalog kwik pen, Lantus solostar pen, Trulicity pen, glyburide - metformin, amitriptyline, and cetirizine. 

The patient's vital signs in emergency room were: temperature (T) -  98.1, blood pressure (BP) 175/81, respiratory rate (R) - 18, pulse rate - 96, and pulse oximetry - 96% (room air). The patient reported having continued dizziness, fatigue and sore throat. Notable lab values included glucose - 338 and glycated hemoglobin (HbA1c) 11.1. Urinalysis showed abnormalities that may be consistent with urinary tract infection (UTI). The patient was started on treatment with intravenous (IV) fluid normal saline, ceftriaxone and vancomycin. Blood cultures grew Bacillus.  The patient was evaluated by infectious disease consult and opined that the blood culture was felt to be contaminant and did not need treatment with intravenous antibiotics. Repeat surveillance blood cultures were advised. The patient was started on Bactrim and discharged home.

No, medical necessity for the inpatient stay is not established upon review of the submitted medical records.
Evaluation in the emergency room showed that patient was afebrile with slightly elevated blood pressure. The patient denied any fever, headache, chest pain, shortness of breath, nausea, vomiting or diarrhea.  Labs showed white blood cell (WBC) count 6.26 on the day of admission and it was 5.8 on the following day.

Continued inpatient hospital stay is justified and medically necessary when a patient's symptoms, signs, labs and imaging indicate severe illness, high risk of deterioration, unstable comorbid conditions and the need for high intensity, complex and frequent interventions and evaluation. Inpatient care is recommended when a patient's symptoms, signs, imaging data, and labs suggest a moderate to severe illness.  The judgement of severity and risk as based on assessment of medical factors in the context of known and generally accepted medical knowledge prevalent. Moderate to high intensity interventions that are required for evaluation and management of the condition also justify an inpatient level of care. Final factors to take into account when judging whether an inpatient admission is medically necessary is the availability of evaluation and management in the alternate setting in an expeditious manner, as mandated by the patient's clinical condition, and appropriate for the patient's medical condition. 

For the duration, the patient was afebrile and had stable vital signs. The patient did not have new symptoms or intractable pain that would require continued management in an inpatient setting. The patient was tolerating oral intake and was clinically stable. Physical exam for this duration did not show any new exam findings that would necessitate further work up in an inpatient setting. Lab results were stable and did not reveal abnormalities that would indicate further need for work up or change in management plan in an inpatient setting. During the above duration, there were no new investigations ordered  / work up initiated, and there was no change in management plans that would justify / necessitate continued inpatient stay in the hospital. During the above duration, the patient's diagnosis had been established clinically and based on the results of the investigations. The patient was hemodynamically stable and afebrile. Examination findings were not concerning and the patient's medical problems did not pose an immediate high risk of deterioration. The patient was not in acute distress and in view of these facts of the patient's  clinical status, the illness was in the post-acute phase and ongoing risk of deterioration was low since diagnosis had been established and patient was responding appropriately to the treatment. The patient did not have any acute complications during this time. No high frequency, high complexity, or high risk procedures or interventions were necessary during this period of time. Since the intensity of interventions was routine, ongoing inpatient care was not medically necessary during this time. With a low severity of illness in the post acute phase and low intensity of interventions during this time, with relative clinical stability, lack of comorbid unstable conditions, and lack of intractable symptoms, ongoing inpatient care was not medically necessary for the above dates.