Diagnosis: lower leg swelling.
Treatment: Inpatient stay.

The insurer denied the inpatient stay. The health plan's determination is upheld.

The patient is a male who presented to the emergency department (ED) with bilateral leg swelling. The patient has a past medical history of diabetes mellitus (DM), seizures, meningioma, and post multiple resections. The patient reported that his swelling is spreading up to his hips and abdomen. The patient also noted shortness of breath, usually with jogging. In the ED, his initial blood pressure (BP) was 181/104, repeated blood pressure (BP) was 147/95, heart rate (HR) 70 beats per minute (BPM), and temperature 98.3.

His physical examination revealed mild crackling in the lower lobes bilaterally. There was mild edema in the lower abdomen. His lower extremity (LE) revealed pitting edema. The patient was admitted to the hospital with diagnosis of congestive heart failure (CHF) versus acute nephrotic syndrome.

The Inpatient Hospital Admission was not medically necessary for this patient. The patient presented with edema of lower extremities and lower abdomen. He had mild shortness of breath and his BP was elevated. The work up revealed presence of nephrotic syndrome and not congestive heart failure. The patient responded to IV diuretics well and was subsequently switched to oral medications.

The patient's condition and management did not reach level of inpatient admission. A lower level of care would be more appropriate.