Diagnosis: Dizziness; Chest pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial modified.

This patient is a female with a history of Type II Diabetes, Asthma, Hypertension, Hyperlipidemia, and gastroesophageal reflux, tobacco and alcohol dependence, that was transported to the Emergency Room by Emergency Medical Services (EMS) for complaints of dizziness, midsternal chest pain, dyspnea, diaphoresis, nausea and vomiting. On admission to the Emergency Room, the patient had a blood pressure of 169/93, a normal heart rate. A battery of testing was completed. There was a normal EKG, normal chest x-ray, CT of the head was normal, blood testing revealed low magnesium and potassium, troponin was normal with normal brain natriuretic peptide (BNP). The patient was admitted for cardiac and neurological consultation. An echocardiogram revealed a grade 1 diastolic dysfunction, a carotid ultrasound revealed right carotid stenosis, bilateral lower extremities Doppler ultrasound was negative. The remainder of the cardiac enzymes were negative. The patient was treated for the electrolyte imbalance, treated for her hypertension, and was discharged with follow up visits to the primary care physician, podiatry and ophthalmologist.

According to the MCG 23rd Edition guidelines for chest pain and dizziness, an inpatient hospitalization could have been considered for an extended period of observation of approximately 1 day (24 hours) however, there is no evidence that a 3 day inpatient hospital stay was indicated as the vast majority of the testing could have been done as an outpatient. Therefore, because a 24 hour observation would have been sufficient, the denial for coverage is partially medically necessary.

The carrier's denial of coverage for the inpatient admission is modified. Approve a specified date range. Deny another date range.