Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Genitourinary
Treatment:  Inpatient Hospital

The health plan denied the inpatient hospital admission.  The denial was upheld.

This is a patient with a past medical history of human immunodeficiency virus (HIV) / acquired immunodeficiency syndrome (AIDS) (last CD4 count 74 with current result greater than [>] 600), Kaposi's sarcoma, and syphilis, who presented to the emergency department with increased scrotal swelling and full body pain with difficulty urinating without straining.

On presentation, the patient was afebrile with blood pressure 116/88, heart rate 106, respiratory rate 20, and with oxygen saturation 99% on room air.  The exam otherwise noted scrotal and penile swelling with mild erythema in addition to bilateral thigh swelling.  Lab results showed white blood cell count (WBC) 6.9, Hemoglobin (HGB) 8.9, platelets 392, sodium (NA) 142, potassium 4.3, blood urea nitrogen (BUN) 18, creatinine 0.8, and liver function tests within normal limits.  A stool for occult blood was negative.  A urinalysis did not show evidence of an infection.  A testicular ultrasound showed extensive diffuse scrotal wall edema and skin thickening with fluid collection at the base of the penis and no evidence of acute epididymitis, orchitis, or abscess.  An electrocardiogram (EKG) showed no acute ischemia or arrhythmia.  The patient was brought into the hospital with the assessment that he had bilateral scrotal and penile swelling for months in addition to dysuria and bilateral leg swelling with a plan for surgery consultation, 24-hour urine for protein, consideration of infectious disease consultation given the history of HIV and syphilis, and possible renal consultation.

A computed tomography (CT) scan of the abdomen and pelvis noted right lower lobe infiltrate with a right pleural effusion in addition to extensive penile swelling and edema.  He was seen by surgery with the assessment that he had chronic scrotal swelling and with recommendation for scrotal elevation without other acute intervention needed.

The patient remained hemodynamically stable without fever, hypotension, or tachycardia.  A repeat complete blood count (CBC) and comprehensive metabolic panel (CMP) were stable.  A second stool was noted to be positive for occult blood with the third stool negative.  An echocardiogram noted a normal ejection fraction without a regional wall motion abnormality or abnormal valve function.  He was seen by hematology with the assessment that he had no acute hematology or oncology needs and with recommendations to consult infectious disease, given his history of Kaposi's sarcoma and gastroenterology, to assess whether he needed an endoscopy.  

A discharge summary was dictated, after which the patient was noted to have 1/3 stool tests positive for occult blood.  A gastroenterology consultation was obtained with the assessment that the patient had abdominal pain and likely colitis without a fever or leukocytosis and with plans for a proton pump inhibitor (PPI) and esophagogastroduodenoscopy (EGD) and colonoscopy the following Monday.
The patient remained hemodynamically stable without a fever, hypotension, or tachycardia.  No acute medical issues were noted with plans for a colonoscopy.
No new acute medical issues were noted with plans for a colonoscopy.
The patient remained hemodynamically stable without fever, hypotension, or tachycardia.  The plan was to continue to await an EGD and colonoscopy.
The patient remained hemodynamically stable and underwent an EGD showing a large polypoid non-circumferential mass with no active bleeding or stigmata of recent bleeding noted.
He was hemodynamically stable without any new acute issues.  He was on all oral medications.  He refused labs and a colonoscopy.  He was given a 24-hour discharge notice, which he refused to sign.

The health plan's determination is upheld.  The requested health service/treatment of inpatient stay was not medically necessary.  As noted above, this patient presented with chronic scrotal swelling that was not associated with any acute issue requiring inpatient care (no hemodynamic instability, torsion, concern for infection, concern for a congestive heart failure (CHF) exacerbation requiring ongoing prolonged IV diuresis).  The patient subsequently appears to have stayed in the hospital after 1 of 3 stools came back positive for blood, and there was concern for possible colitis.  It is unclear why this result required ongoing hospital stay in the absence of fever, tachycardia, leukocytosis, worsening anemia, or abdominal pain requiring frequent administration of IV opiates.  It is also unclear, given the provided documentation, why the endoscopy was delayed.  Acute inpatient admission was not medically necessary for this hemodynamically stable patient without significant bleeding with chronic scrotal edema, for which there was no concern for infection, torsion, or need for immediate surgical treatment.  Inpatient care was not medically necessary.