Diagnosis: Dyspnea.
Treatment: Inpatient stay.
The insurer denied the inpatient stay.
The health plan's determination is upheld.

This case involves a man admitted to the hospital with dyspnea, orthopnea, and elevated blood pressure. After running out of his blood pressure medications for several days, the patient reported several days of symptoms. There were no complaints of chest pain, palpitations, or cough. A chest x-ray was completed, which showed no acute cardiopulmonary disease. Initial blood pressure was quite elevated to 208/96. Oxygenation status was normal, and the heart rate was normal. Glasgow Coma Scale calculated at 15. Cardiac enzymes were drawn in the emergency department and were negative. The patient was placed on telemetry in an observation unit bed for monitoring.

Based on the provided documentation, inpatient admission was not medically necessary. The clinical scenario is a patient with underlying hypertension and chronic kidney disease who ran out of medications and presented to the emergency department (ED) with elevated blood pressure and dyspnea. There is no sign of severe volume overload, pulmonary edema, refractory to diuretic therapy, or acute coronary syndrome. Cardiac enzymes are negative, invasive cardiac work-up completed within 24 hours, shows no evidence of obstructive disease. The patient was restarted on guideline-directed medical therapy with a beta-blocker and ACE (Angiotensin-converting enzyme) inhibitor and discharged home. There is no documentation of repeated intravenous (IV) diuretic therapy administration for refractory heart failure symptoms. The patient has nonischemic cardiomyopathy, likely due to hypertension, and was appropriately treated with reinitiation of a baseline antihypertensive regimen. There were no major electrolyte derangements, severe hypoxemia, or other hemodynamic instability. The entire work-up can be completed at a lower level of care.