Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcohol Intoxification And Shortness Of
Breath
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

This male presents to the emergency department (ED) with non-exertional dyspnea and cough for a week. He was intoxicated.  The patient has a history of asthma and polysubstance drug abuse.  

The patient had an abnormal electrocardiogram (EKG) consistent with pericarditis, no evolution. His urine was positive phenylcyclohexyl piperidine (PCP). The patient's echocardiogram was normal, with left ventricular (LV) function normal and no pericardial effusion. The patient was treated with intravenous (IV) fluids, Pepcid, thiamine, folic acid and his inhalers. He underwent an alcohol withdrawal protocol. Serial electrocardiograms (EKGs) and enzymes were unremarkable. The patient was discharged.

No, inpatient level of care was 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; and highlighted in the orders for care. 

In this case, the patient was mainly admitted for treatment of his chronic alcohol intoxication. While his electrocardiogram (EKG) was abnormal, no further interventions were indicated or required. His symptoms were atypical and unlikely to be representative of acute coronary syndrome or acute pericarditis and no evidence of tamponade. Exam and cardiac findings were normal. Biomarkers and electrocardiogram (EKG) showed no evidence of acute ischemia ("abnormal EKG" was borderline). His chest x-ray (CXR) was normal. The echocardiogram showed no wall motion abnormality or pericardial effusion.

The physicians' treatment did not reflect any serious concern about patient's cardiac condition.  Orders did not include medical therapy for acute coronary syndrome (ACS) such as intravenous (IV) heparin, dual antiplatelet inhibitors, high dose beta blockers or intravenous (IV) nitroglycerin (NTG).   

The letter of appeal was carefully considered but offered no evidence to support inpatient level of care. The only cardiac care provided was telemetry, frequently performed in a lower level of care. The patient was admitted for monitoring and subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care. This patient had no evidence of coronary artery disease (CAD). All tests showed absence of ischemia.  While there is always a potential for an adverse event (and in this case a very low probability), one did not happen, and no actual treatment was added. Even if a diagnosis of pericarditis was confirmed, that would not have required inpatient level of care.

Milliman criteria requirements were not fulfilled as there was never any evidence of acute coronary syndrome (ACS) present.  Inpatient care was neither indicated nor prescribed. Telemetry, serial electrocardiograms (EKGs) and cardiac enzymes do not require an inpatient level of care. All testing and therapy would be appropriate, safe and guidelines consistent to be 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.