Diagnosis: pulmonary embolism.
Treatment: inpatient stay.
The insurer denied an inpatient stay.
The health plan's determination is overturned.

The patient is a female with a medical history of obesity, sleeve gastrectomy, gastroesophageal reflux disease, history of COVID-19 infection, and recent cesarian section childbirth who presented with symptoms of chest pressure exacerbated with breathing, coughing, laughing, and dyspnea on exertion for a few days prior to admission. She was found to have bilateral pulmonary emboli on computed tomography (CT) chest angiogram. She was initiated on a Heparin infusion and transitioned to Lovenox.

Inpatient Hospital Admission was medically necessary for this patient.
This patient presented with symptoms of chest pressure exacerbated with breathing, coughing, laughing, and dyspnea on exertion for a few days prior to admission. In the emergency room, she was afebrile, hemodynamically stable, her heart rate was 91 beats per minute, she had an oxygen saturation of 99% on room air and was in no acute distress. On physical exam, she had no documented jugular venous distension, had a normal work of breathing without accessory muscle use, clear breath sounds on auscultation of the chest but had moderate respiratory discomfort on exertion. On computed tomography (CT) chest angiogram she was found to have bilateral pulmonary emboli. Her echocardiogram did not demonstrate right ventricular dysfunction/strain or diminished cardiopulmonary reserve and her electrocardiogram (EKG) did not demonstrate ST-segment elevation.
However, she was at a high risk for complications upon initiation of anticoagulation due to recent surgery (cesarian section) that could increase the risk of catastrophic bleeding. Therefore, an Inpatient Hospital Admission was medically necessary for this patient.