Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Hematemesis 
Treatment:  Inpatient Admission

The proposed treatment, inpatient admission, is deemed medically necessary. 

The patient is a male with a history of hypertension and peptic ulcer disease who presented to the ER for further evaluation/management of hematemesis for one month.  Intake vitals were notable for significantly hypertensive blood pressure of 161/123 and mild tachycardia to 106.  Examination was notable for two-plus pitting edema involving the bilateral lower extremities.  Further diagnostic testing with electrocardiogram (EKG) and laboratory tests revealed significant abnormalities.  As such, the patient was admitted to the inpatient medical service with guarded prognosis.  He received high flow supplemental oxygen via face mask with continuous positive airway pressure (CPAP) support given poor oxygenation along with aggressive titration of antihypertensives until target blood pressure was reached. Cardiology and Gastroenterology referrals submitted for assistance with further evaluation/management.  The patient eventually improved with prescribed therapies and was discharged in stable condition. 

This is a male with a history of hypertension and peptic ulcer disease who presented to the ER for further evaluation/management of hematemesis for one month.  Intake vitals were notable for significantly hypertensive blood pressure of 161/123 mmHg and mild tachycardia to 106 beats per minute.  Examination was notable for two-plus pitting edema involving the bilateral lower extremities.  Further diagnostic testing with EKG and laboratory tests reveals significant abnormalities including evidence of frequent premature ventricular contractions (PVCs), prolonged QT, non-specific T wave abnormalities and significant hypernatremia with serum sodium 151.  As such, the patient was admitted to the inpatient medical service with guarded prognosis.  He received high flow supplemental 40% oxygen via face mask with ten millimeters CPAP support given poor oxygenation along with aggressive titration of antihypertensives until target blood pressure was reached.  Cardiology and Gastroenterology referrals submitted for assistance with further evaluation/management and performed two-dimensional echocardiogram, which revealed significant left ventricular hypokinesis and depression ejection fraction of 37%.  The patient eventually improved with the prescribed therapies and was discharged in stable condition. 

Evidence of severe hypertensive blood pressure, mild tachycardia, EKG with evidence of frequent PVCs, prolonged QT, non-specific T wave abnormalities, significant hypernatremia with serum sodium 151 and two-dimensional echocardiogram with evidence of significant left ventricular hypokinesis and depression ejection fraction of 37% confirms that this was an extremely high risk patient for whom inpatient medical care was medically necessary/warranted.  Hence, the patient's care could not have been safely furnished in a less intensive setting without adversely affecting patient's safety or outcome.  For these reasons, the proposed treatment inpatient admission is deemed medically necessary.