Diagnosis: CAD, renal disease, diabetes
Treatment: Inpatient admission

The proposed inpatient admission was not medically necessary; inpatient level of care was neither indicated nor provided.

The patient is a male on chronic dialysis who missed several treatments due to being "sick". He went to the emergency department (ED) for evaluation due to progressively worsening shortness of breath and chest tightness in the setting of recent nausea, vomiting, and diarrhea and non-adherence with outpatient dialysis. He was admitted for purpose of hemodialysis (HD). At that time, he denied chest pain (CP), or shortness of breath (SOB), and was comfortable lying in bed. He has a history of coronary artery disease (CAD), hepatitis and diabetes. HD was performed without complications, then cramps. Hemodynamically stable and no significant or unexpected electrolyte imbalance, the patient was discharged per his normal routine.

The patient had missed his dialysis for a week and came to hospital for the procedure. Per ED, he did not have chest pain or dyspnea. Nephrology arranged ultra-filtration, he did well and was discharged. There was neither hemodynamically instability nor critical electrolyte imbalance. He was discharged on his usual medications.

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, his presentation was consistent with his missing HD sessions, but he did not have significant fluid overload or electrolyte imbalance or hemodynamic instability. Thus no criteria met for inpatient level of care.

The letter of appeal was carefully considered but it offered no evidence to support inpatient level of care. The only care provided was hemodialysis, usually performed in a lower level of care. The patient was admitted for monitoring and acute dialysis therapy did not require an inpatient level of care. There was no complex care that required inpatient care. This patient had no evidence of active CAD. All tests showed absence of ischemia. While there is always a potential for an adverse event, one did not happen and no actual treatment was added.

Milliman criteria requirements were not fulfilled as there was never any evidence of acute coronary syndrome (ACS) present. The ED notes did not suggest any active ischemia, nor was there hemodynamic instability, nor was the patient treated as angina. 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.