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202307-165857

2023

Fidelis Care New York

PPO

Cancer

Inpatient Hospital

Medical necessity

Overturned

Case Summary



Diagnosis: chest pain/cough.
Treatment: inpatient hospital.
The insurer denied the inpatient hospitalization.
The health plan's determination is overturned.

The patient is a female with a medical history of hypertension who presented with symptoms of right-sided chest/back/upper quadrant pain, dyspnea, and cough with bloody sputum (hemoptysis). She was found to have acute bilateral pulmonary emboli on computed tomography (CT) chest angiography. She was started on treatment with Lovenox and transitioned to an oral anticoagulant Eliquis.

Inpatient Hospital Admission was medically necessary for this patient.
Based on the severity of illness, intensity of required therapy, and guidelines provided, the inpatient level of care was medically necessary. This patient with a medical history of hypertension presented with symptoms of right-sided chest/back/upper quadrant pain, dyspnea, and cough with bloody sputum (hemoptysis). She was found to have acute bilateral pulmonary emboli on computed tomography (CT)CT chest angiography with pulmonary infarcts. Although, she was afebrile, hemodynamically stable with an oxygen saturation was 100% on room air, she required full dose anticoagulation. She was started on treatment with Lovenox and transitioned to an oral anticoagulant Eliquis. Per the criteria provided, in the setting of hemoptysis and pulmonary infarcts, she would have required an inpatient level of care to monitor for further/worsening of lung hemorrhage/hemoptysis while on the anticoagulation therapy (Lovenox).

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