Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Kidney Disease Stage 5
Treatment: Inpatient Admission
The insurer denied the inpatient admission.
The health plan's determination is overturned. 

The patient is a male who initially was sent to the emergency department by his nephrologist to initiate hemodialysis due to worsening renal function. His pertinent history included chronic kidney disease stage 5 and hypertension. Additional history was pertinent for no prior established dialysis access. His initial hemodynamics were stable. The initial examination documented the patient as alert and oriented. The initial laboratory testing revealed a white blood cell count (WBC) of 4.1, hemoglobin 9.3, platelets (Plt) 148, blood urea nitrogen (BUN) 123, creatinine 15.53, carbon dioxide (CO2) 23, potassium 4.7, and his estimated glomerular filtration rate (eGFR) was 4.
The electrocardiogram (EKG) was without significant abnormalities. The patient was placed in the hospital thereafter with an impression of end-stage renal disease. The treatment plan included establishment of dialysis with plans for new initiation of hemodialysis thereafter. Nephrology was consulted of whom had an impression of chronic kidney disease progressing to end stage renal disease with no uremic symptoms, stable acid/base, and electrolytes. Recommendations were to proceed with tunneled catheter placement to initiate hemodialysis. The dialysis catheter was placed. The first session of hemodialysis was initiated thereafter. A second session of hemodialysis was performed. Dizziness was noted with both sessions. The third dialysis session was successfully completed. Outpatient hemodialysis arrangements were pursued. Maintenance hemodialysis was continued while awaiting arrangements. The patient was discharged with outpatient dialysis arrangements in place.

Based on the clinical documentation provided, evidence based literature and standards of care, an acute inpatient level of care was indicated as medically necessary for the entire admission. Wouk notes end-stage renal disease (ESRD) is diagnosed when kidney function is no longer adequate for long-term survival without kidney transplantation or dialysis. Primary care clinicians should refer people at risk of ESRD to nephrology to optimize disease management. Kidney transplantation typically yields the best patient outcomes, although most patients are treated with dialysis. The decision to initiate dialysis is best made through shared decision-making. Because most patients with ESRD elect to receive hemodialysis, the preservation of peripheral veins is important for those with stage 3 (III) to 5 (V) chronic kidney disease. A palliative approach to ESRD is a reasonable alternative to dialysis, particularly for individuals with limited life expectancy, with severe comorbid conditions, or who wish to avoid medical interventions. Controlling blood pressure in patients receiving dialysis improves mortality. Volume control through adequate dialysis and sodium restriction can help optimize hypertension treatment in these patients.[1]
The patient had a history of chronic kidney disease who was directed to the hospital by his nephrologist for concerns of rapid worsening of renal function with need to initiate hemodialysis. His serum creatine worsened from 11.08 to 14.41 to 15.53 in about a month duration. The BUN followed a similar trajectory. The patient did not have prior dialysis access established. Treatment included placement of a dialysis catheter and new initiation of hemodialysis. Interventional radiology placed an internal jugular dialysis catheter and nephrology guided hemodialysis. Once the initial sessions were completed and outpatient hemodialysis arrangements were made, the patient was discharged.

The health plan's determination of medical necessity is overturned in whole.