Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute Kidney Failure/Urinary Tract Infection
Treatment: Inpatient Hospital Stay
The health plan denied the inpatient hospital stay. 
The health plan's determination is overturned.

This is a male with a past medical history of an aneurysm of the anterior cerebral artery and chronic kidney disease (baseline creatinine 1.7) who presented to the emergency department with intractable hiccups for the past 3 days, in addition to urinary frequency.
On presentation, he was afebrile with blood pressure 132/82 millimeters of mercury (mmHg), a heart rate of 98 beats per minute (bpm), a respiratory rate of 18/minute, and with an oxygen saturation of 97% on room air. An exam otherwise noted intractable hiccupping. Labs resulted with a white blood cell count (WBC) of 13.3, a Hemoglobin (HGB) of 11.4, a sodium of 131, a potassium of 3.2, a blood urea nitrogen (BUN) of 32, a creatinine of 1.97, an aspartate aminotransferase (AST) of 71, an alanine aminotransferase (ALT) of 34, an alkaline phosphatase of 116, a total bilirubin of 0.4; lipase was normal, troponin was 0.07, and a creatinine kinase of 1335. A urinalysis was positive for a urinary tract infection. An electrocardiogram (EKG) showed sinus tachycardia. The patient was given Thorazine and Baclofen in the emergency department with no relief. He was subsequently brought into the hospital with concerns for intractable hiccups, acute kidney injury, rhabdomyolysis, and urinary tract infection and plans for intravenous (IV) fluids, renal ultrasound, follow up labs, consideration of further intracranial imaging, Reglan, and IV antibiotics.
The patient was hemodynamically stable without fever, tachycardia, or hypotension. Hiccups had subsided. Repeat creatinine was 1.7, WBC was 8.3, and creatinine kinase improved to 1016. A renal ultrasound was performed noting mild right hydronephrosis with echogenic focus on the right side of the bladder concerning for nephrolithiasis obstructing the ureter vesicular junction with correlation with a computed tomography (CT) scan recommended.
On the following day, the patient remained hemodynamically stable. Creatinine kinase had improved to 498, WBC was 7.6, and creatinine had improved to 1.42. Urology saw the patient with recommendation that a CT scan be performed to further assess the possibility of obstructing nephrolithiasis. The patient declined further work-up and left against medical advice with a prescription for Cefpodoxime despite being educated on the risks of possibly developing sepsis or worsening acute kidney injury.
The issue in question is whether care at the inpatient level of care was medically necessary.
I overturn, in whole, this health plan's determination of medical necessity.

Yes, inpatient stay was medically necessary. As previously noted, this patient with urinary tract infection, acute kidney injury, concern for obstructing nephrolithiasis, and concomitant hydronephrosis was at high risk for worsening acute kidney injury and systemic illness with sepsis and was appropriate in this setting for inpatient-level care.
This is a patient who presented with intractable hiccups that did not require inpatient-level of care but also had concomitant urinary tract infection with acute kidney injury and hydronephrosis with concerns for obstructing nephrolithiasis placing him at high risk of sepsis and need for IV antibiotics and possible urologic intervention. It is noted that he had a short length of stay, but this was in the setting of him leaving against medical advice and being cautioned about the risks of potential sepsis and critical illness rather than him being medical stable for discharge. Inpatient level of care was medically necessary for this patient urinary tract infection, acute kidney injury, concern for obstructing nephrolithiasis, and concomitant hydronephrosis all placing him at risk of systemic illness and sepsis and requiring close monitoring.