Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Shortness of breath 
Treatment: Acute inpatient hospital stay 

The insurer is denied coverage for acute inpatient hospital stay. The denial is overturned. 

This is a female patient with a history of breast cancer status post mastectomy on the left, diabetes mellitus, and hypertension on furosemide. The patient presented to the Emergency Department with complaints of progressive shortness of breath on exertion that had begun several weeks ago; she was a smoker. The patient denied chest pain and palpitations with shortness of breath. The patient also reported complaints of lumbar back pain for several weeks with radiation to the front. The patient's physical examination revealed that the patient could speak in full sentences; her oxygen saturation was 91-93% on room air. The patient indicated that she was unable to lay flat and that she slept on two pillows and unable to walk more than one block and she had lower extremity edema. The patient's hemoglobin was 8, creatinine was 3.6 and blood urea nitrogen was 48. The patient's brain natriuretic level was 393. The patient's chest x-ray revealed mild fluid overload. The patient's urinalysis was positive for leukocyte esterase and bacteria. The patient underwent a bladder scan, which revealed a postvoid residual of 200 mL of urine. The patient had lower extremity pitting edema. The patient had used Lasix at home, and her symptoms did not improve. She was admitted to the hospital with shortness of breath on exertion and hypoxia. Cardiology and Nephrology were consulted. The patient's transthoracic echocardiogram report revealed left ventricular ejection fraction of 66-70%, mild LV diastolic dysfunction, mildly dilated left atrium, mild mitral valve regurgitation, and moderately elevated pulmonary artery systolic pressure. The patient's computed tomography (CT) scan of the chest revealed a 6.5 x 4 mm pulmonary nodule in the lingual region. There was mild cardiomegaly. There was extensive bilateral mosaic continuation of the lungs, most consistent with small airway disease. There were patchy opacities in the left lower lung, possible atelectasis. The patient was stabilized and discharged. 

Based on the review of the medical record and literature, acute inpatient hospital stay is considered medically necessary for this patient. The patient had multiple medical problems that required acute inpatient admission that included acute kidney injury on chronic kidney disease, acute congestive heart failure exacerbation that required intravenous (IV) diuretic therapy, bacteriuria that required IV antibiotics, and respiratory distress that required BIPAP oxygen administration. At hospital presentation, the patient was found to have hypoxemia with a chest x-ray that revealed mild fluid overload and elevated lactic acid. The patient required consultations from both cardiology and nephrology. Due to these clinical reasons, acute inpatient admission was appropriate and necessary for this patient. 

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient. 

The carrier's denial of coverage for the acute inpatient hospital stay should be overturned. The medical necessity is substantiated.