Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left upper quadrant pain, malfunctioning PICC line
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

This female patient has multiple medical problems including multiple bariatric surgeries with complications of tear of sleeve, total parental nutrition (TPN) for short gut syndrome, chronic malnutrition, and hyperthyroidism.  She was hospitalized for sepsis secondary to colitis.  She was diagnosed with hyperparathyroidism.  

The patient presented to the ED with a malfunctioning peripherally inserted central catheter (PICC) and electrolyte abnormalities but left against medical advice (AMA).  She was discharged back to NH (nursing home) but was returned to the emergency department (ED) because NH (nursing home) did not accept her.  

The patient was placed in an observation level of care for placement.  Left peripherally inserted central catheter (PICC) was removed and right peripherally inserted central catheter (PICC) was placed.  While in observation, she complained of left upper quadrant (LUQ) pain.  She became febrile, hypotensive and tachycardia.  Abdominal pain increased and she developed diarrhea.  Vital signs (VS) were as follows: temperature 100.6, heart rate 108, respiratory rate 18, blood pressure 100/71, and oxygenation 96%.  Exam was remarkable for left upper quadrant (LUQ) tenderness.  Labs were as follows: white blood cells (WBC) 15.8, hemoglobin (Hgb) 6, and lactate 2.4.  Chest x-ray showed nothing abnormal detected (NAD).  Coronavirus (COVID) was negative.  Abdominal/pelvic computed tomography (CT) was consistent with pancolitis.  She was admitted with a diagnosis of sepsis.  Plan of care included intravenous fluids (IVF), intravenous (IV) antibiotics, parental nutrition (PN) and Dilaudid for pain management.  Chronic anemia was treated with erythropoietin (EPO).  She was transitioned to oral antibiotics and remained at an inpatient level of care pending scheduled thyroid/parathyroidectomy.  

Surgery was performed.  Oral antibiotics were continued.  The patient continued to have abdominal pain.  Small bowel enteroscopy was performed and colonoscopy was performed.  Oral antibiotics were discontinued.  Antibiotics were resumed after a temperature of 100.8.  Blood cultures were positive for Klebsiella pneumonia, but no source was identified.  She was treated with 14 days of oral antibiotics.  A new peripherally inserted central catheter (PICC) was placed.  She remained on parental nutrition (PN) due to inadequate oral intake.  The patient was cleared for discharge.

No, the proposed treatment was not medically necessary.
This patient has multiple chronic medical conditions with several complications of bariatric surgery and recurrent colitis.  The patient was admitted with sepsis without focal infection.  She was hemodynamically stable.  Her maximum temperature was 101.  She had normal oxygenation.  Soon after admission, the patient was transitioned to oral antibiotics.  She continued to have abdominal pain that was managed with Dilaudid.  She intermittently had low grade fevers.  She continued to receive parenteral nutrition and underwent endoscopic studies, which confirmed colitis.  Blood cultures were positive, but no source was identified.  This was managed with oral antibiotics.  

This patient's presentation does not meet Milliman Care Guidelines (MCG) Sepsis and Other Febrile Illness without Focal Infection criteria for inpatient admission because the patient did not have:  hemodynamic instability, bacteremia, hypoxemia, or altered mental status.  She also did not have failure of outpatient treatment, tachypnea, new coagulopathy, dehydration, end-organ dysfunction,  temperature (T) greater than (>) 104.9, parenteral antimicrobial regiment that must be implemented on an inpatient basis, or isolation indicated that cannot be performed outside hospital setting.