Diagnosis: Dizziness, Low Blood Pressure.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a patient with a history of female transitioning, hypertension (HTN), multiple sclerosis (MS), and bipolar disorder who was admitted with complaints of (c/o) dizziness after seeing the primary medical doctor (PMD) and low blood pressure. The vital signs were significant for a blood pressure (BP) of 95/50. The physical exam was notable for no apparent distress (NAD). Lab work was notable for leukocytosis. A chest x-ray (CXR) showed no acute disease. The patient was diagnosed with hypotension rule out (r/o) sepsis and was treated in the emergency department (ED) with intravenous fluids (IVF) and IV antibiotics. Infectious disease (ID) was consulted and noted the patient had a chronic leukocytosis and recommended observing off of antibiotics. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

No, the hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the ED with c/o dizziness after seeing the PMD and low blood pressure. The patient did not have associated high-risk features, such as acute renal failure, congestive heart failure, or liver failure, nor did the patient have any hemodynamic instability, bowel obstruction, diabetic ketoacidosis, or appendicitis. The patient was hemodynamically stable, did not have pyelonephritis, ascending infection, toxic appearance, unstable vital signs, or immunosuppression. The patient also did not have any acute hearing loss, double vision, fixed neurologic deficits, severe headache, associated head trauma, fever, high clinical suspicion for central vertigo or cerebrovascular accident (CVA), cerebellar infarct or hemorrhage, vertebrobasilar insufficiency, acute suppurative labyrinthitis, intractable nausea/vomiting or inability to ambulate. The patient was evaluated by ID and they recommended discontinuing antibiotics as the leukocytosis was chronic in nature. The patient presented with dizziness and low blood pressure, which responded to fluids, and ID consultation, and these interventions could have been safely and appropriately provided at a lower level of care.