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

This is a female patient with a history of hyperlipidemia and polysubstance abuse. The patient was sent to the Emergency Department (ED) from the clinic to rule out tuberculosis. The patient's chief complaints were cough and night sweats with occasional hemoptysis. The patient reported no history of tuberculosis (TB) exposure. The patient denied weight loss. The patient had a negative PPD in early 2019 and then in late 2019 she tested positive. The patient had been started on isoniazid (INH) in early 2019. The patient's vital signs at ED presentation were: temperature 98.6F, heart rate 87, respiratory rate 20, blood pressure 131/74 mm Hg, and oxygen (O2) saturation 98 % on room air. The patient's respirations were non-labored. The patient's lungs were clear to auscultation and her cardiovascular and abdominal exam were unremarkable. The patient's white blood cell (WBC) count was 11.7K, hemoglobin 12.7; liver function tests, electrolytes, BUN/Creatinine levels were all within normal limits. The patient's chest x-ray did not reveal any acute pathology. The patient was paced in airborne isolation to rule out tuberculosis. The patient was medically stable and discharged home.

Based on the review of the medical record and literature, inpatient admission was not medically necessary. The patient remained stable after admission. Given this patient's normal chest x -ray, the patient's chances of having active tuberculosis were not high. The patient could have been placed on Observation status. Sputum AFB smears could have been done every 8 hours. As it turned out, the patient's sputum smears were negative. The patient was treated with isoniazid/rifampin weekly regimen and was discharged home. The patient remained afebrile and was hemodynamically stable. The patient's workup in the Emergency Department showed low likelihood of active tuberculosis, and did not warrant inpatient admission. The patient's further diagnostic testing and management could have been done at the Observational level of care.
Thus, inpatient admission was not medically necessary.

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.