Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pleural Effusion.

Treatment: Inpatient admission.

The insurer has denied coverage for inpatient admission.  

The denial is upheld. 

This is a female patient with history of hypertension (HTN), hypothyroidism, mitral valve prolapse (MVP), hyperlipidemia (HLD), and premature ventricular contractions (PVC). The patient had been diagnosed with pericarditis and pleural effusion and was undergoing work up as an outpatient. The patient presented to emergency department (ED) with complaint of weakness, pleuritic chest pain and subjective fevers.
Her presenting  vital signs were: Temperature 98.3F, Heart Rate 76, Respiratory Rate 14, Blood Pressure 160/77 mm Hg, and oxygen (O2) saturations 100% room air. The patient was awake and alert, in no respiratory distress. There was no jugular venous distension (JVD); the lung exam revealed vesicular breath sounds with decreased air entry at the lower bases. The cardiovascular system (CVS) S1 S2 was normal. Her abdomen was soft, and non- tender; no edema was present.
White blood cell count (WBC) was 10.1K, Hb 10g, electrolytes were within normal limits (WNL), BUN/ Creatinine WNL, ESR was elevated to 108, CRP was high. Troponin was negative. EKG revealed no acute ischemic changes. BNP was normal D dimer was elevated. Lactate was WNL. Chest x-ray revealed (CXR) left pleural effusion with left basilar atelectasis / infiltrate. A computed tomography (angiography CTA) was done that revealed a  pleural effusion with underlying atelectasis and a small pericardial effusion. The patient was admitted to the hospital with a diagnosis of pleural effusion. Pulmonology and Infectious Diseases were consulted. The patient underwent thoracentesis. 600 cc Pleural fluid drained. It was a lymphocyte predominant exudate. Cultures were negative. Cytology was negative. No evidence of malignancy. A bone marrow biopsy was obtained that was also negative for malignancy. After a period of medical stability she was discharged home on tapering steroid dose with outpatient follow up.

This patient did not need acute inpatient hospitalization. The patient has had chronic symptoms over past several months. The patient's pleural effusion and pericarditis were not new. The patient was undergoing evaluation of same in outpatient setting. The patient was afebrile in ED. Was hemodynamically stable, in no respiratory distress. Oxygen saturation did not reveal any hypoxia - 95 to 100% on room air. There was no evidence of sepsis, myocardial infarction, pulmonary embolism. This patient did not need acute hospitalization. Thoracentesis and bone marrow biopsy are both ambulatory surgery procedures. There was no change in the patient's condition to warrant an urgent inpatient hospitalization. The patient was already being evaluated for the same in outpatient setting.  Pleural effusions are routinely worked up in outpatient setting. This patient just underwent diagnostic procedures. The patient was treated with oral medications.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

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