Diagnosis: Anemia.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

This female with a history of hypertension (HTN), chronic obstructive pulmonary disease (COPD) and alcohol abuse presented to the emergency department complaining of light headedness, shortness of breath and cough.

The patient's vital signs revealed the following: temperature 98.2, pulse 108. respiratory rate 16, and blood pressure 126/50. The patient's exam was remarkable for pale and right-sided neck swelling. Her labs revealed the following: white blood cell (WBC) count 19.5, hemoglobin/hematocrit 6/21.2, platelets 554, prothrombin time (PT) 14.7, partial thromboplastic time (PTT) 24.8, and international normalized ratio (INR) 1.2. Basal metabolic panel (BMP) was normal. The patient's lactate was 7.4, brain natriuretic peptide (BNP) 20.7, troponin .019, and power of hydrogen (pH) 7.26 to 7.4. The patient's chest x-ray showed no abnormality detected (NAD). Electrocardiogram (EKG) showed normal sinus rhythm (NSR).

The patient was admitted with systemic inflammatory response syndrome (SIRS). Plan of care included intravenous (IV) antibiotics and blood transfusion. Day two, the patient's vital signs were stable and she was afebrile. She denied chest pain, dyspnea, and abdominal pain. Hemoglobin improved to 7.5, white blood cell (WBC) count was 7.1, and lactate was 3.8. COVID testing was negative. Ultrasound (US) of the neck revealed a hypo echoic mass. She was continued on intravenous antibiotics. She was scheduled for an outpatient colonoscopy. Day three, vital signs were stable and she was afebrile. Urine analysis (U/A) revealed large leukocyte esterase. Blood cultures were negative and antibiotics de-escalated. The patient was discharged.

No, the proposed treatment was not medically necessary.
The inpatient admission was not consistent with generally accepted medical standards.

This patient was admitted with systemic inflammatory response syndrome (SIRS) of unknown etiology after presenting with cough and shortness of breath. She was hemodynamically stable and afebrile. Diagnostic studies were remarkable for leukocytosis, anemia and acidosis. She did not have renal failure or severe electrolyte abnormality. Electrocardiogram (EKG) was normal. She did not have active bleeding. She did not have altered mental status. The patient received a blood transfusion and was empirically treated with intravenous antibiotics. She was found to have a urinary tract infection (UTI). She had not failed an observation level of care. She remained clinically stable during the hospital stay. She remained hemodynamically stable and afebrile. Her hemoglobin remained stable. Based on these findings and lack of failure of an observation level of care, the acute inpatient level of care was not medically necessary.