Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Elevated white blood cells
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is an adult female. This patient was admitted for elevation of white blood cells (WBC) to 16000. This lab abnormality was detected during routine workup for angiogram and placement of an infrarenal aortic stent, which in turn was needed because of symptomatic peripheral vascular disease (PVD). She was sent to the emergency department (ED) for evaluation. Medical history was notable for history of occluded aortic bypass that had been found on a computed tomographic angiography (CTA) done 8 months ago. Past medical history was also positive for depression, schizophrenia, restless leg syndrome, posttraumatic stress disorder, anxiety disorder, polysubstance abuse (on methadone), and seizure disorder.

In the ED, the patient did not describe any symptoms to suggest infection or that otherwise explained the WBC elevation. She described her known PVD symptoms. Physical examination showed that she was afebrile with normal vital signs [heart rate 82, respiratory rate 16, blood pressure 119/80, oxygen sat 96% (percent)]. Exam also showed dusky toes with nonpalpable pedal pulses (her baseline), but she had Doppler signals. She had no other signs of infection. Initial lab studies were notable for WBC 14.6, glucose 159, aspartate aminotransferase (AST) 42, alanine aminotransferase (ALT) 68. These were normal, except for WBC elevation. The patient was admitted and underwent extensive workup of her leukocytosis. Infectious disease consult was obtained. She was covered empirically with broad-spectrum antibiotics and started on intravenous (IV) heparin. Over the next few days, she had continuing workup for her leukocytosis as well as preoperative workup for her planned aortic intervention. Her serial WBC tests ranged between 10000 and 12000. Her remaining workup was negative for infection or other clear explanation. Ultimately, her providers concluded that she had idiopathic (unexplained) WBC elevation. Antibiotics were discontinued. On day # (number) 7, she underwent successful endovascular therapy of the aortic lesion with a stent. She was discharged on day #8.

The inpatient hospital admission was not medically necessary.

The admission under review was not medically necessary. The patient was not acutely ill when the WBC elevation was incidentally detected during preoperative workup for treatment of her aortic lesion. She had multiple stable chronic conditions, including PVD, malperfusion of her toes, substance abuse, and schizophrenia. Her thorough workup in the ED was reassuring for the absence of any acute problem. She could have been safely discharged from the ED with a plan to perform workup of her WBC elevation as an outpatient. The inpatient workup conducted could have been done in the outpatient setting. The patient was treated with broad spectrum antibiotics and IV heparin, but these were not necessary treatments because she did not have any evidence of sepsis or acute ischemia. The inpatient hospital admission was not medically necessary.