Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pleuritic pain; rib fracture
 
Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial is upheld. 

This patient is a male with a history of hypertension, diabetes mellitus, hyperlipidemia, chronic renal disease and status post thoracotomy.  He presented to the Emergency Department (ED) with a complaint of right rib pain.  The pain was pleuritic in nature.  The patient reported falling in the bathroom three days prior to presentation.  The patient denied fever.  There was no loss of consciousness.  There was no head trauma.  The patient complained of some intermittent dizziness on ambulation for some time now. At presentation to the ED, vital signs included a temperature of 97.8F, a respiratory rate of 18, a heart rate of 75, a blood pressure of 131/76 and oxygen saturations of 97 % on room air.  The patient was in no acute distress.  Lungs were clear.  Breath sounds were equal bilaterally.  The patient was alert and oriented x3.

The white blood cell (WBC) count was 10.7, the hemoglobin was 8 and the blood urea nitrogen (BUN)/ Creatinine was 98/7.4.  Other electrolytes were unremarkable.  A urinalysis showed proteinuria and hematuria consistent with diabetic renal disease.  Arterial blood gases (ABGs) included a pH of 7.35, a partial pressure of carbon dioxide (pCO2) of 37, a partial pressure of oxygen (pO2) of 71 and an oxygen saturation of 95% on room air. Cardiac enzymes were negative.  An EKG showed no ischemic changes.  Imaging revealed fractures of the right 9th and 10th rib.  There was no pneumothorax.  A CT confirmed the same.  Old changes of a thoracotomy were seen and there was some atelectasis in the left lower lobe.  A pulmonary embolism was ruled out. A sonogram showed no obstruction or hydronephrosis, as well as medical renal disease.

The patient was treated with pain medications, nebulizers, a Lidocaine Patch and intravenous (IV) hydration.  The patient was seen by thoracic surgery who did not recommend any acute intervention other than pain medications and Incentive Spirometry. The patient remained stable after admission. The BUN/ Creatinine also remained unchanged and was 97/7.5 several days after presentation. The patient was seen by a Renal consultant who felt the results were secondary to diabetic nephropathy. Flomax was started for retention symptoms.  The patient had been followed by a Nephrologist before admission who had been preparing him for dialysis.  The patient was discharged home.

This patient did not need acute hospitalization.  He could have been placed in Observation status while diagnostic evaluation and treatment were undertaken.  The patient was seen by multiple specialists and no acute interventions were recommended.  The patient remained afebrile and hemodynamically stable after admission.  Labs remained unchanged.  The patient only had two ribs that were fractured.  There was no evidence of flail chest and no hypoxia.  There were no acute changes in the CT other than the fractured ribs.  His renal failure was chronic and he was under the care of an outside Nephrologist for the same.  The patient did not have any volume overload or electrolyte imbalances that warranted acute dialysis.

The insurer acted reasonably, with sound medical judgment, and in the patient's best interest.

Based on the above, the medical necessity for the inpatient admission is not substantiated.  The insurer's denial is upheld.