Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chronic kidney disease

Treatment:  Inpatient hospital services

The insurer has denied inpatient hospital services.  The denial was upheld.

This is a male patient who was seen in the hospital.  He had a past medical history of hypertension, hyperlipidemia, chronic kidney disease, cervical stenosis of spine and an immune disorder.  The patient was noted to have recently started dialysis.  The patient complained of progressively worsening kidney function and right knee pain.  The patient recently left earlier in the day against medical advice and came back for treatment.  The patient was evaluated by surgery to have an arteriovenous (AV) fistula placed as a better method of hemodialysis treatment.  The patient had a PermaCath placed.  He patient complained of right knee pain that comes and goes on its own, but has gotten worse in the last three to four days prior to presentation.  His pain level was a 10/10.  The patient admitted to a history of dry cough on and off.  The patient had a white blood cell count of 15.3, a red blood cell count of 3.06, a hemoglobin of 9.1, a hematocrit of 28.5%, platelets 338, a sodium of 138, a potassium of 3.6, a chloride of 100, a dioxide level of 25, a blood urea nitrogen (BUN) level of 52, a creatinine of 3.02, a glucose of 112, a calcium of 8, a phosphorus of 2, and a magnesium of 1.9.  The patient had a blood pressure of 108/70 with a pulse of 78, respirations of 18, an oxygen saturation of 98% and a temperature of 98.1.  On examination, the right knee was tender and painful, as well as warm.  The patient was having an acute gout flare.  The patient received methadone, Keppra, prednisone, Renagel, Os-Cal, and Procardia.  The patient was then discharged.

Analysis and Rationale:
  
The medical literature indicates that admission is indicated for patients with chronic renal failure if there is evidence of cardiac arrhythmias of immediate concern, recurrent seizures, encephalopathy, impaired hemostasis with active bleeding, superinfection not treatable in an outpatient setting, unexplained syncope, hemodynamic instability, uremic symptoms that are severe or persistent despite observational care treatment, significant respiratory findings that are severe or persistent despite observational care treatment, clinically significant metabolic or electrolyte abnormality that are severe or persistent despite observational care treatment, urgent treatment of renal failure necessary on an inpatient basis due to vascular access not previously established or not usable, continuous intravenous infusion of anticoagulant, vasoactive or antiarrhythmic medication needed, pulmonary artery catheter monitoring needed or temporary pacemaker placement required.  

The documentation indicated that the patient was seen for progressively worsening kidney function, as well as right knee pain.  The patient recently started dialysis.  The patient had none of the above medical indications for inpatient admission to an acute care hospital.  The patient's condition was appropriate for a level of observational care rather than inpatient level of care.  As such, the inpatient hospital services at the acute level of care are not medically necessary and the prior determination is upheld.  The insurer acted reasonably, with sound medical judgment, and in the patient's best interest. 

The carrier's denial of coverage for the inpatient hospital services at the acute level of care is upheld.  The medical necessity is not substantiated.