Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male. He presented with abdominal pain radiating to the back. The patient has a history of hypertension and diabetes. The patient denied chest pain, SOB (shortness of breath), and headache. The patient was hypertensive, afebrile and had normal oxygenation. The patient's labs showed creatinine of 1.35, BNP (brain natriuretic peptide) 208, troponin 0.08, then 0.07. EKG (electrocardiogram) showed NSR (normal sinus rhythm) with LVH (left ventricular hypertrophy). CXR (chest x-ray) was negative. Abdominal CT was negative. The patient was treated in ED (emergency department) for hypertension. Therapy included IVF (intravenous fluids), ASA (acetylsalicylic acid), low dose beta blocker, PO (by mouth) nifedipine, and insulin. The plan was to admit to telemetry and to continue above therapy, including enzymes. Patient felt good and left AMA (against medical advice). The patient was discharged with diagnosis of flank pain.

No, the Inpatient Admission is not medically necessary.

Determination of level of care is primarily dependent on the actual care a patient receives and, whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results; it is highlighted in the orders for care.

In this case, the patient's symptoms were atypical, present for weeks and unlikely to be representative of acute coronary syndrome. The patient had severe hypertension but no signs of malignant hypertension. His cardiac findings were normal. Biomarkers and EKG showed no evidence of acute ischemia: Troponin of 0.07 does not indicate acute MI (myocardial infarction) in the setting of severe hypertension and chronic renal failure. "Abnormal EKG" was consistent with his hypertension. His CXR was normal. His echocardiogram showed no wall motion abnormality. The physicians' treatment did not reflect any serious concern about patient's cardiac condition as ACS (acute coronary syndrome).  Admission orders did not include medical therapy for ACS such as IV heparin, dual antiplatelet inhibitors, high dose beta blockers or IV NTG (nitroglycerin).   

The letter of appeal was carefully considered but it offered no evidence to support inpatient level of care. The statement that the treatment ordered and testing performed "could not have been done in the outpatient setting" is not consistent with guidelines or community care. The only cardiac care that was provided was telemetry, which is frequently performed in a lower level of care. The patient was admitted for monitoring and the subsequent tests and medical therapy provided did not require an inpatient level of care. There was no complex care that required inpatient care. This patient had no evidence of CAD (coronary artery disease). In fact, all tests showed absence of ischemia.  While there was always a potential for an adverse event, one did not happen and no actual treatment was added.

Milliman criteria requirements were not fulfilled on any of the multiple guidelines included in the appeal letter.  It is not the presence of any diagnosis, but rather the treatment required to treat, which determines the level of care. There was never any major evidence of ACS, hypertensive emergency, malignant arrhythmias, severe dehydration, hemodynamically significant renal failure or renal colic present.

All testing and therapy that were provided would have been appropriate, safe and guidelines -consistent in lower level of care. Thus, inpatient level of care was not medically necessary.

The denial explanation was consistent with guidelines and usual community care.