Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male. He has history of hypertension, hyperlipidemia, congestive heart failure, history of renal transplant secondary to IgA (Immunoglobulin A) nephropathy, now has renal insufficiency. He had surgery for perianal abscess a day before his presentation to the ED (emergency department). He presented with one-week history of shortness of breath, and chest pain of one day duration. The chest pain was left-sided, dull, 6/10 (six out of ten) in severity and associated with intermittent lower extremities edema. He had no history of abdominal pain, nausea, vomiting and diarrhea.

In the ED (emergency department), the patient was hemodynamically stable and afebrile. His physical examination was normal. His chest x-ray was normal, and his EKG (electrocardiogram) showed non-specific ST and T changes. His CBC (complete blood count) revealed Hb/HCT (hemoglobin/hematocrit): 6.8/21.3. The troponin levels were less than 1, and BNP (brain natriuretic peptide was) 286. His BUN (blood urea nitrogen) and Cr (Creatinine) were 90 and 3.9 respectively. His COVID-PCR (coronavirus disease polymerase chain reaction) was negative. 

The patient received two units of PRBCs (packed red blood cells). The CT (computerized tomography) of the abdomen was negative for intraabdominal hematoma, and revealed mild duodenitis. Surgery was consulted for the evaluation of the abscess drainage site. No surgical intervention was recommended and the patient was advised to complete the 10-day course of Augmentin. Cardiology was consulted, and acute coronary syndrome was ruled out. GI (gastroenterology) was consulted and advised to continue the patient on IV (intravenous) PPI (proton pump inhibitor) BID (twice daily). The EGD (esophagogastroduodenoscopy) was scheduled. 

The patient felt better and denied any nausea, vomiting, dark stools or blood in the stools. The EGD (esophagogastroduodenoscopy) done revealed dilated esophagus, large esophageal diverticulum, gastritis, non-bleeding gastric ulcer and multiple, nonbleeding duodenal ulcers with no evidence of bleeding. He was continued on IV (intravenous) PPI (proton pump inhibitor) BID (twice daily). His Hb/HCT (hemoglobin/hematocrit) was 8.0/25.1. His anemia was attributed to underlying kidney disease.  

The patient tolerated the solid diet and he was discharged home on PPI (proton pump inhibitor) BID (twice daily) and advised follow up in three months.

The Inpatient admission was not appropriate and medically necessary for the management of this patient's condition. 

The patient presented with shortness of breath and chest pain. Cardiology evaluation ruled out acute coronary syndrome. His chest x-ray and Covid-19 (Coronavirus disease) evaluations were negative. The CT (computerized tomography) abdomen did not reveal any intra-abdominal hematoma. The shortness of breath was attributed to anemia. He received two units of blood and was started on IV (intravenous) PPI (proton pump inhibitor) BID (twice daily) as per the GI (gastroenterology) recommendation. He was scheduled for EGD (esophagogastroduodenoscopy), which revealed esophageal diverticulum, and non-bleeding gastric and duodenal ulcers. Throughout his hospital stay, he had no evidence of active GI (gastrointestinal) bleeding or hemodynamic instability due to anemia. Therefore, given this clinical scenario, he could have been appropriately and safely managed at the lower level of care.