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

The patient is a male with history of asthma, hypertension and prediabetes. He presented to emergency room (ER) with shortness of breath.

The patient was found to have elevated troponin. The ER (emergency room) records documented diffuse anterolateral T-wave inversion. He was diagnosed with acute coronary syndrome. Additionally, he had hypoxia requiring O2 (oxygen) supplementation. Also, lactic acidosis, acute kidney injury, hypocalcemia and hypomagnesemia were found. Based on this information in the ER (emergency room), the decision was made for inpatient admission.

The admission note outlines that the patient had chest tightness for three days. During the inpatient hospital stay, the chest pain did not recur, and the patient's troponins quickly trended down, ruling out acute coronary syndrome. He was discharged following treatment for asthma exacerbation with nebulizers and inhalers.

The health plan denied coverage of full hospitalization service as not a medically necessity. This was based on the grounds that the patient's shortness of breath presentation to the ER (emergency room) required no breathing machine, in addition to absence of collapsed lung or other condition, treatment, or monitoring requiring inpatient admission. This denial is being appealed.

Yes, the Inpatient admission was medically necessary.
On ER (emergency room) presentation, the patient was found to have elevated troponin. The ER (emergency room) records have documented diffuse anterolateral T-wave inversion. He was diagnosed with acute coronary syndrome. The ER (emergency room) presentation with shortness of breath could be related to asthma or could be anginal equivalent in the setting of his cardiac risk factors. The decision for inpatient admission for ACS (acute coronary syndrome) was based on troponin elevation and documented EKG (electrocardiogram) finding in the ER (emergency room).

The standard of care for ACS (acute coronary syndrome) patients is to be admitted as inpatient for further evaluation and management. The lower level of care would not be the proper acuity given the patient's diagnosis of ACS (acute coronary syndrome) in the ER (emergency room).

Therefore, given the above, the Inpatient admission was medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Review of entire records reveal that criteria for inpatient admission was based on suspected diagnosis of acute coronary syndrome, thus making the inpatient admission medically necessary.