Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pulmonary Embolism
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This patient has a past medical history of recent breast augmentation and tummy reduction surgeries. She presented to the emergency department with a two-week history of shortness of breath. The shortness of breath was associated with laying flat and walking short distances. At the same time, the patient denied calf tenderness or chest pain. The patient also denied a fever, chills, leg swelling, chest pain, and palpitations.
Upon evaluation in the emergency department, the patient underwent a computed tomography (CT) angiogram of the chest that demonstrated one subsegmental pulmonary embolus in the right lower lobe.
Vital signs were a temperature of 98.1 degrees Fahrenheit, pulse rate 80 beats per minute (bpm), respiratory rate 18 breaths/minute, blood pressure 128/77, and oxygen saturation 100% on room air.
The patient was in no acute distress. The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. The lungs were clear to auscultation without wheezes, rales, or rhonchi. The patient had a regular heart rate and rhythm. The abdomen was non-tender, non-distended. The patient had healing scars in the abdomen and breasts without erythema, edema, tenderness.
The rest of the physical exam was unremarkable. Laboratory evaluation revealed a sodium of 136, potassium 3.7, chloride 105, bicarbonate 23, blood urea nitrogen (BUN) 14, creatinine 0.72, and glucose 96. Liver function tests were normal. Troponin was normal. The white blood cell count was 5.8, hemoglobin 11.1, hematocrit 33.5, and platelets 390.
The patient was admitted to the hospital with an acute pulmonary embolism. An echocardiogram was ordered to evaluate for ventricular strain. The patient was initially started on subcutaneous injections of Lovenox but was subsequently switched to Apixaban.
An echocardiogram was a technically difficult study. The right ventricle was not adequately visualized. It was noted that the patient had no hypoxemia even with ambulation.
In the hospital, the patient remained in stable clinical condition and was transitioned to outpatient.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
The pulmonary embolism severity index (PESI) is a risk-stratification tool that predicts the 30-day outcome of patients with pulmonary embolism using 11 clinical criteria. Based on the calculations, this patient received 45 points. Therefore, she belonged to Class I, Very Low Risk: 0-1.6% 30-day mortality in this group. Patients with a very low risk of mortality are usually recommended treatment of pulmonary embolism as an outpatient.
There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care with subsequent transition to outpatient care, rather than admission to an inpatient level of care. Overall, this patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. 
She belonged to a very low-risk group for adverse outcomes because of the acute pulmonary embolism. The hospital stay was very short and neither the severity of the patient's condition nor the complexity of the services provided rose to the level of acute inpatient care.