Diagnosis: Shortness of Breath
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

The patient is a female with a history of hypertension, allergic reaction triggers unknown, who was hospitalized for acute symptoms of shortness of breath and angioedema. The patient had presented to the emergency room and was treated with epinephrine and steroids. The patient was evaluated by specialties such as Pulmonary Medicine and Allergy Service. The testing performed during the hospitalization was unremarkable.

No, the proposed treatment of inpatient hospitalization does not meet the criteria for medical necessity.
Upon review of medical records, including emergency room records, laboratory testing records, hospitalization treatment and testing records, it was not evident that the patient was having hemodynamic instability at the time of admission for inpatient care. Upon presentation to the emergency room, the patient was found to be afebrile, with stable blood pressure and elevated heart rate. Her physical examination had not revealed significant pulmonary function issues such as wheezing, and her ear nose and throat (ENT) examination did not reveal obstruction in the oropharynx that showed airway compromise. Her laboratory testing records show elevated white blood cell count, which was likely due to prior oral steroid use. She also did not present with altered mental status, and was noted to be alert, awake and oriented. She continued to be monitored for symptoms of worsening angioedema/breathing problems, which could be performed at a lower level of care, such as observational stay, rather than inpatient care. Furthermore, the testing such as evaluation for angioedema, radiologic imaging studies can also be performed at the observational care level. In summary, there were insufficient findings on her physical examination, or vital signs to suggest that she was hemodynamically instable at the time of inpatient admission.