Appeal type: Medical necessity
Decision: Upheld

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

The patient presented to the emergency department with complaints of generalized weakness, dizziness, and fever that started one week before the presentation. On the day of the admission, his symptoms became worse. At the time of the initial evaluation, the patient denied chest pain, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, or constipation. After the initial evaluation in the emergency department, the patient was started on intravenous antibiotics.
When seen by the admitting physician, the patient's temperature was 100.5 degrees Fahrenheit, blood pressure 130/77, pulse rate 120 beats per minute (bpm), respiratory rate 20, and oxygen saturation 95% on room air. The head, eyes, ears, neck, throat (HEENT) exam was within normal limits. The lungs were clear to auscultation. The cardiovascular exam was unremarkable. The abdomen was soft and nontender. The rest of the physical examination was within normal limits.
Laboratory evaluation revealed that the white blood cell count was 4.3, hemoglobin 13.0, hematocrit 38.4, and platelets 81. Sodium was 134, potassium 3.2, chloride 93, bicarbonate 26, blood urea nitrogen (BUN) 19, creatinine 1.3, and glucose 103. Transaminases were slightly elevated (alanine aminotransferase (ALT) 57, aspartate aminotransferase (AST) 64). The lipase was normal. The urinalysis was unremarkable.
A computed tomography (CT) scan of the chest did not show acute abnormalities.
The patient was admitted to the hospital with a diagnosis of probable sepsis. Blood, urine culture, and tick panel were sent. An infectious disease consultation was requested. The patient received potassium supplements. At the time of the admission, the patient was diagnosed with thrombocytopenia, which was attributed to possible sepsis.
During the hospitalization, the patient underwent an abdominal ultrasound that demonstrated dilated common bile duct of uncertain etiology. The patient was evaluated by an infectious disease specialist. Per the recommendations of the infectious disease specialist, the patient was continued on intravenous antibiotics while waiting for culture results, the tick panel was pending.
According to the progress note, the patient was feeling much better. He had two episodes of loose stools. The patient denied abdominal pain, weakness, or dizziness. He tolerated his diet. It was indicated in the same note that the patient was afebrile overnight, and continued to be afebrile.
On that day the patient underwent a magnetic resonance cholangiopancreatography (MRCP), which demonstrated mild biliary dilation without gallstones or choledocholithiasis.
The patient's condition continued to improve. According to the progress note, the patient was feeling much better, had no fever, chills, or sweats. There was no abdominal pain. The patient expressed a desire to go home.
During the hospital stay, the patient's blood cultures remained negative. The urine culture demonstrated no growth. The peripheral blood smear showed no intracellular organisms. The patient was started on oral Doxycycline to complete the 10-day course.
Reportedly, the patient had urinary retention because of an enlarged prostate. A Foley catheter was placed.
The patient was evaluated by a gastroenterologist because of abnormal liver enzymes. The gastroenterologist stated that the patient's liver enzymes were improving while in the hospital. The gastroenterologist recommended outpatient followup with possible endoscopic ultrasound/endoscopic retrograde cholangiopancreatography (ERCP) to be performed in the future. The tick panel resulted positively for Ehrihia Chaffeensis.
At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient stay was not medically necessary at the acute inpatient level of care.
The workup performed in the hospital revealed that the patient had Ehrlichiosis. Ehrlichiosis is caused mainly by Ehrlichia chaffeensis. Symptoms include fever, chills, headache, malaise.
In this clinical case, the patient had typical symptoms of this infection, although these symptoms were nonspecific. The initial evaluation in the hospital demonstrated that the patient had a high fever. At the same time, the results of the physical exam were not particularly alarming. The patient had some abnormalities in the laboratory studies, which required additional attention and further evaluation. The patient had very mild hyponatremia and mild hypokalemia, which were successfully treated quickly with the administration of intravenous fluids and potassium supplements. The patient's BUN and creatinine were slightly elevated, pointing toward mild dehydration. The patient had a slightly abnormal transaminases.
At the time of admission, the patient was placed on intravenous antibiotics while awaiting blood cultures, and tick panel results. According to the records, the patient's clinical condition improved quickly, with a resolution of fever in the first two days of hospitalization.
The patient had an extensive workup, which included an abdominal ultrasound and magnetic resonance cholangiopancreatography (MRCP). Although these studies were not completely normal and demonstrated mild dilatation of the common bile duct (CBD), there was no need for any immediate procedure performed during the hospital stay.
The patient also had urinary retention that was treated with insertion of a Foley catheter and administration of Flomax. In general, this kind of treatment does not require admission at the acute inpatient level of care.
Taking into consideration all of this information, care could have been provided at a lower level to perform the workup of fever and abnormal transaminases. The severity of the patient's condition and the complexity of the services provided did not rise to the level of acute inpatient care.
The patient remained hemodynamically stable throughout the entire hospitalization, his fever resolved within the first two days of hospital admission. He had only slightly abnormal transaminases, which could have been related to his infection. The diagnostic studies performed for the evaluation of abnormal liver enzymes did not require admission at the acute inpatient level of care. Although the patient had thrombocytopenia, there were no signs of bleeding, and the patient did not require any treatments to correct this problem. Finally, the patient had urinary retention, which was treated with insertion of the Foley catheter and Flomax. This was not a procedure necessitating admission at the acute inpatient level of care. Therefore, the services listed above could have been performed at a lower level of care.