Diagnosis: Sarcoidosis.
Treatment: Inpatient hospital admission
The insurer has denied coverage for inpatient hospital admission.
The denial is upheld.

The patient was a male who presented to the Emergency Department (ED) with 2-day history of chest pain. The patient reported that the pain was severe with 10 out of 10 pain severity, and was accompanied with some shortness of breath. The patient reported that he had been having chest pain on and off for many months. The patient had been evaluated at another hospital for this similar presentation. The patient's computed tomography (CT) of the chest had revealed a nodular density and the biopsy was non-conclusive. The patient was treated with Prednisone for suspected sarcoidosis.

In the ED, the patient's initial vital signs were: temperature 98.7 F, blood pressure 151/107, heart rate 99, respiratory rate 20, and oxygen (O2) saturations 99%. On exam, the patient was mildly distressed but was otherwise unremarkable. The patient's lab results showed white blood cell count (WBC) of 5K, hemoglobin of 16.1; the patient's electrolytes and BUN/Cr were within normal limits. The patient's troponin was negative, and the patient's electrocardiogram (EKG) showed no ischemic changes. The patient's computed tomography (CT) scan of the chest revealed a similar lung nodule in the left lung, which was unchanged from the CT scan done. The patient was treated with pain medications. The patient's clinical picture was consistent with sarcoidosis. That was also the assumption during his prior work up. The patient remained stable after admission, and was treated with oral medications. The patient was then discharged the following day.

Based on the review of the medical record and the literature, this patient did not need acute inpatient hospitalization. The patient was stable to be discharged home after evaluation and treatment in Emergency Department (ED). The patient was hemodynamically stable and his lab and physical exam was unremarkable. The patient's computed tomography (CT) scan of the chest was unchanged from his previous CT scan for which the patient's workup was consistent for sarcoidosis. There were no new clinical findings that required inpatient level of care and monitoring. The patient had negative cardiac enzymes and a normal electrocardiogram. The patient's chest pain was not consistent with myocardial infarction. Inpatient admission was not medically necessary for this patient.

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

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