Diagnosis: Hemoptysis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a patient with a past medical history significant for metastatic renal cell carcinoma with metastasis in the lungs, adrenal glands, and lymph nodes who underwent treatment for that and developed pneumonitis. She presented to the hospital with hemoptysis and a fever.
The patient stated that she initially had a dry nonproductive cough that became more bothersome. She had one episode of hemoptysis. On that day, the patient underwent a computed tomography (CT) scan of the chest that was performed and demonstrated no evidence of pulmonary embolism. It showed no infiltrates, however, revealed progression of the disease with a worsened right mass with compression of the bronchi and a pleural effusion. She was evaluated in the emergency department and was discharged home with a prescription for Z-Pak. The patient noted that over the course of 2 days the paroxysmal cough became worse. Therefore, she was referred to the hospital again for a bronchoscopy.
The patient was admitted to the hospital for evaluation by a pulmonologist.
During the hospital stay, the patient underwent a bronchoscopy. This study demonstrated near complete (90%) obstruction of the lower bronchus intermedius from extrinsic compression. The patient underwent balloon dilation up to 8 millimeters (mm). The bronchoscopy revealed right lower lobe and right middle lobe bronchi obstruction. There were mucous plugs in the right upper lobe posterior segment and right middle lobe, which were suctioned. The patient received treatment with Zosyn for what was considered post obstructive pneumonia. Subsequently, she was transitioned to oral antibiotics.
During the hospital stay, the patient started radiation treatment. The patient remained in stable clinical condition.
At issue is the medical necessity of an inpatient stay.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
The patient presented to the hospital with complaints of a cough, shortness of breath, and hemoptysis. She had only one single episode of hemoptysis, and it was clearly indicated in the notes that the CT scan of the chest showed no pulmonary embolism, or clear signs of pneumonia or pneumonitis. The patient's symptoms were most likely related to worsening metastatic disease.
The review of the medical records clearly demonstrated that the patient had no evidence of acute respiratory failure. There was no documentation of severe airflow or ventilation abnormalities, overwhelming evidence of infection, or severe pulmonary arterial hypertension.
The bronchoscopy with balloon dilation performed during the hospital stay is an outpatient procedure, including the initiation of radiation therapy, which is usually performed on an ambulatory basis.
Taking into consideration all of this information, there is not overwhelming evidence that either the severity of the patient's condition or the complexity of services provided rose to the acute inpatient level of care.