Diagnosis: Rule out rule out deep vein thrombosis (DVT)/pulmonary embolism (PE) and congestive heart failure (CHF)

Treatment: inpatient admission

The insurer denied coverage for inpatient admission. The denial is upheld.

This patient is a female with history of hypertension (HTN), hyperlipidemia (HLD), diabetes mellitus (DM), and morbid obesity who presented to the emergency department (ED) with complaints of increasing swelling of both lower extremities and increasing dyspnea on exertion over several months. The patient has also noted a 50lb weight gain over the past few months. The patient had been prescribed compression stockings by her primary physician but she had not been using them. Vital signs at presentation to ED: Temperature 97.9 F, Heart Rate 93, Respiratory Rate 18, Blood Pressure 184/84 mm Hg, oxygen (O2) saturations 99%. The patient was awake and alert with no jugular venous distension, lungs were clear, cardiovascular system was normal, and there was bilateral pitting pedal edema with skin pigmentation noted.

White blood cell (WBC) was 8.2K, Hb 8.5, BUN/ Creatinine 28/1.45, Troponin was 0.01, EKG No acute ischemic changes Pro BNP elevated to 131D Dimer was elevated to 281.Chest x-ray revealed (CXR) some perihilar and left lower infiltrate. No pleural effusion. The patient was admitted to rule out rule out deep vein thrombosis (DVT)/pulmonary embolism (PE) and congestive heart failure (CHF). The patient was given Lasix in ED and 1 dose of Levaquin even though pneumonia not likely given normal WBC and there was no fever or other clinical signs of pneumonia. A DVT study was negative for DVT of the lower extremity, V/Q scan was read as low probability of PE. ECHO revealed left ventricular hypertrophy and ejection fraction was 65%.

The patient did not need acute inpatient hospitalization. She had been on Amlodipine which may have been also contributing to patient's edema. The patient improved with Lasix. The patient was discharged the day after with outpatient follow up.This patient did not need acute inpatient hospitalization. She could have been placed in Observation while diagnostic testing and treatment were initiated. The patient had DVT and PE ruled out. The patient did not have acute CHF. She did not have pneumonia she was responding to Lasix. The patient remained afebrile and hemodynamically stable after admission to the hospital. The patient was tolerating oral intake. The patient was stable for discharge on oral medication with close follow up in the outpatient setting. She was afebrile and hemodynamically stable WBC 6.7 Hb 9.2. PE, myocardial infarction (MI) and CHF and DVT had been ruled out. The patient was saturating to 99% was awake alert lungs were clear. The patient could have been switched to oral Lasix.

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

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