Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal/Pancreatitis
Treatment: Inpatient Hospital
The health plan denied the inpatient stay as not medically necessary. The health plan's determination is overturned.

The patient is a male with hyperlipidemia, coronary artery disease (CAD), prior deep vein thrombosis (DVT), gastric ulcers, and skin cancer who presented with nausea and vomiting, and weeks of malnutrition and was diagnosed with necrotizing pancreatitis and was transferred to another facility for an endoscopic drainage. On presentation he was in shock, requiring Norepinephrine. Labs included a white blood cell count (WBC) of 39, a sodium of 117, a bicarbonate of 17, and a blood urea nitrogen (BUN) of 92. A-line and central lines were inserted, a Norepinephrine drip, Vancomycin and Zosyn were continued There was concern for intestinal pneumatosis.

The patient became obtunded, tachypneic, and was placed back on the ventilator. A CT( computerized tomography) scan of the abdomen/pelvis was performed given ongoing illness and showed air in the gastric wall; an esophagogastroduodenoscopy (EGD) found severe gastritis. A thickened gallbladder wall also noted, but interventional radiology (IR) declined placement of a cholecystostomy tube, as the patient was not a good candidate due to instability. Oliguric acute kidney injury (AKI) developed with no response to Furosemide. Fluconazole was changed back to Caspofungin. A goals of care discussion was held, and the patient was made do not resuscitate (DNR) and a decision was made to not re-initiate dialysis. Another meeting with family was held, and the patient was made comfort measures only (CMO) status. The patient underwent palliative extubation and expired 1.5 hours later.

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

Yes. While this patient had an extremely prolonged admission and while there were occasional, brief periods of stability, his entire course was marked by frequent decompensation, novel infections, re-development of a variety of organ failures (encephalopathy, shock, variety of cardiac rhythm issues including atrial fibrillation and prolonged pauses, waxing and waning respiratory failure, acute renal failure). Even when he was at his most stable, he remained extremely tenuous and at high risk of worsening. This was in large part due to a complicated and persistent complicated intra-abdominal infection (essentially managed through months of an intra-abdominal catastrophe) that could not be definitively managed with invasive drainage, either by surgery or interventional radiology. This incredibly high degree of severe illness, extreme instability, and frequent decompensation could not have been managed at a rehab (even the long term acute (LTAC) level) and certainly could not have been managed in an observation or outpatient setting. He needed frequent trips to the OR for wound debridement and frequent repeat imaging, often required urgently, the latter both a signifier of how ill he was and a reason he could not have been managed in an LTAC or as an outpatient. Beyond this, he had severe pain requiring a Hydromorphone patient controlled analgesia (PCA) on a continuous rate; this is not something that can be provided in the outpatient/observation setting. Even if the patient had been sent to a rehab (and I do not think he was ever stable enough to do this), he certainly would have returned within days at most given his highly unstable state. While I do not think the provided criteria fully apply here given the unique situation with such an incredibly ill patient, he did have an inability to maintain oral hydration, pancreatic abscess, severe pain requiring inpatient management (Hydromorphone PCA), hemodynamic instability, and acute respiratory failure; all criteria for inpatient admission were present. An inpatient admission was needed for the entire duration of this hospitalization.