Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Genitourinary/Kidney Disorder - Acute Kidney Failure
Treatment: Inpatient Hospital Stay
The health plan denied the Inpatient Hospital Admission as not medically necessary.
The health plan's determination is upheld.

The patient is a female with a past medical history of asthma, diabetes mellitus, eczema, hallucinations, schizoaffective disorder, and morbid obesity, who was brought to the emergency department (ED) due to suicidal ideations and was managed in the psychiatry unit. She was transferred to the medical floor due to poor oral intake and acute kidney injury. The patient complained of three episodes of vomiting and poor oral intake for two days. The vomitus contained food particles, was nonbloody, and nonbilious. She also complained of itching and vaginal discharge. She denied diarrhea, dysuria, fever, chills, abdominal pain, upper respiratory infection symptoms, cough, shortness of breath, chest pain, and palpitations.

The physical exam was within normal limits. The patient had a regular rate and rhythm. The abdomen was soft, nontender to palpation, with normal bowel sounds, without guarding or rebound. The skin exam revealed patches of lichenification and thickening at the elbow flexor areas bilaterally. The patient was alert and oriented to person, place, and time.
The laboratory evaluation revealed that the white blood cell count was 18.9, with a hemoglobin of 12.0, a hematocrit of 38.3, and platelets of 464. Her sodium was 134, with a potassium of 5.0, a chloride of 99, a bicarbonate of 26, a blood urea nitrogen (BUN) of 11.6, and a creatinine of 1.23. 
The patient was admitted with a diagnosis of acute kidney injury with Q-T interval prolongation, attributed to the three episodes of vomiting. The patient denied abdominal pain. She received treatment with Doxycycline and Ceftriaxone, as well as Metronidazole. The patient received intravenous fluids and was started on antiemetics. She was seen by an infectious disease specialist who stated there was no evidence of pelvic inflammatory disease (PID). Therefore, there was no need for the continuation of antibiotics.
The patient received intravenous fluids with resolution of the dehydration. The leukocytosis was also attributed to dehydration and resolved.
The QTC prolongation was likely medication induced. It improved. Before the discharge, the patient tolerated her diet.
There was no documentation that while on the medical floor the patient expressed suicidal ideations. She continued to take a regimen of medications.
The patient remained in stable clinical condition and was discharged.

At issue is the medical necessity of the inpatient hospital admission.

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

The requested health service/treatment of Inpatient Hospital Admission was not medically necessary for this patient.
The patient was transferred to the medical floor from inpatient psych due to several episodes of vomiting and possible dehydration.
However, at the time of the initial evaluation, there was no evidence of severe dehydration or any significant hemodynamic instability. The patient's kidney function was normal. There was no evidence of significant electrolyte abnormalities. There were no signs of uremia or clinically significant metabolic acidosis that was not corrected during the initial period.
There was no evidence of underlying infection.
The mild prolongation of QTCs syndrome did not materialize in any symptoms and resolved quickly.
The patient's dehydration related to several episodes of vomiting was very mild and was easily corrected quickly.
There is no overwhelming evidence that either the severity of the patient's condition or the complexity of services provided rose to the acute inpatient level of care.