Diagnosis: Genitourinary/Kidney Disorder/Chronic Kidney Failure/ESRD
Treatment: Inpatient Hospital
The health plan denied the requested inpatient stay as not medically necessary.
The health plan's determination is upheld.

The patient is a female with a past medical history (PMH) of end stage renal disease (ESRD) on hemodialysis (HD), coronary artery disease (CAD), diastolic heart failure (HF), and hypertension (HTN) who was admitted with complaints of a three-day history of left shoulder pain. Vital signs were remarkable for hypertension (HTN). A physical exam was notable for limited shoulder range of motion (ROM) secondary to pain. Lab work was notable for positive troponin, but stable. Imaging studies included a computed tomography (CT) of the chest which was negative for aortic dissection or pulmonary embolism (PE); a chest x-ray (CXR) showed mild pulmonary edema. An electrocardiogram (EKG) showed normal sinus rhythm (NSR) and an old left bundle branch block (LBBB). The patient was diagnosed with shoulder impingement and was treated with steroids and physical therapy (PT)/occupational therapy (OT). The patient was discharged in stable condition.
What is at issue is the medical necessity of the inpatient level of care.

The health plan's determination of medical necessity is upheld, in whole.

No, the hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with complaints of left shoulder pain that was not considered likely to be acute coronary syndrome (ACS) related, based upon documentation review, and the troponin elevation was thought most likely secondary to ESRD. An EKG did not demonstrate any acute ischemic changes. For the chest pain, the patient's HEART risk score was 6 (slightly suspicious, non-specific repolarization disturbance on EKG, >65YO and 1-3x elevated troponin), indicating that the patient had a moderate score, and not a high score. Given that the patient had stable vital signs, no unstable co-morbidities, a non-ischemic EKG, and negative delta cardiac biomarkers, no new LBBB or newly inverted T-waves believed to be ischemic in origin, and no classic anginal symptoms or other serious or life-threatening cardiopulmonary etiologies, this patient could have been safely and appropriately treated at an observation level of care.
Regarding the provided criteria, the patient did not have acute kidney injury, significantly elevated blood sugar, fever, need or mechanical ventilation, hypertensive emergency, or aortic dissection.