Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Shortness of breath, lower abdominal pain, vaginal bleeding
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a female with a history of iron deficiency anemia and uterine fibroids who presented to the Emergency Department (ED) for an emergency evaluation due to shortness of breath, palpitations for a day, chills and fever, lower abdominal cramping, rash, and vaginal bleeding for two to three days. The patient reported a recent history (one week ago) of uterine fibroid embolization. The patient reported that she was discharged after the procedure with Toradol, gabapentin, Tylenol, tramadol, levofloxacin, Zofran, Prilosec and senna.  

On initial presentation, the patient was febrile (temperature of 100.6 degrees Fahrenheit), blood pressure (BP) was 124/88, pulse was 82 beats per minute (she was later tachycardic at 104), and respirations were 20 breaths per minute. On examination, the patient looked ill, with tachycardia, suprapubic tenderness to palpation, erythema/bleeding of vagina, enlarged uterus, submandibular lymphadenopathy, and bilateral upper and lower extremity morbilliform urticarial rash. Laboratory studies were remarkable for leukocytosis, microcytic anemia, thrombocytosis, eosinophilia, transaminitis (aspartate aminotransferase [AST] / alanine aminotransferase [ALT] 353/335), and proteinuria. 

In the emergency department, the patient was administered Benadryl and steroids.  The treating physician's clinical impression was emergently concerned for Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome secondary to gabapentin, levofloxacin or Toradol.  For management of DRESS syndrome, the patient was kept on intravenous (IV) Benadryl and intravenous (IV) Prednisone.  Although patient was advised to stay in the hospital, the patient decided to leave the hospital against medical advice. The patient was sent home (against medical advice) with prednisone, Augmentin and recommendations to follow up with gynecology (GYN) and her primary care physician (PCP). 

Yes, the inpatient admission was medically necessary.

This patient presented with elevated temperature, lymphadenopathy, elevated liver enzymes, and eosinophilia a week after a uterine artery embolization.  Common complications of uterine artery embolization include pelvic pain, fever, and vaginal discharge, but these are self-limiting in most patients.  The most serious potential complications are introduction of embolic agents into inadvertent vessels, necrosis of the gluteus maximus or limb, or pulmonary embolism. However, the patient was diagnosed with drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome.

Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare, potentially life-threatening drug-induced hypersensitivity reaction that includes skin eruption, hematologic abnormalities (eosinophilia, atypical lymphocytosis), lymphadenopathy, and/or internal organ involvement (liver, kidney, lung). The diagnosis of drug reaction with eosinophilia and systemic symptoms (DRESS) is based upon the combination of clinical features (history of drug exposure, cutaneous findings, systemic findings, such as fever, lymphadenopathy, and visceral involvement) and laboratory findings. Identification and prompt withdrawal of the offending drug is the mainstay of treatment for patients with drug reaction with eosinophilia and systemic symptoms (DRESS). Serial biochemical measurements should be performed to monitor liver function. Severe hepatocellular injury may evolve to acute liver failure and the only effective therapy may be liver transplantation.  It is obvious from the above that drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a very serious condition. 

It is obvious from the above, that drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a serious condition and quick and adequate management is medically necessary. In this patient's case, admission for intravenous (IV) steroids was medically necessary to monitor for any possible worsening of her situation, to investigate which drug was the offending one and to rule out any other possible etiology for her symptoms.