Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Kidney Injury, Epigastric Pain
Treatment: Inpatient Hospital Stay

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

The patient has a past medical history significant for hypertension, hyperlipidemia, and chronic leukocytosis of unknown etiology who presented to the emergency department with complaints of epigastric abdominal pain for 5 days. The abdominal pain was described as a pressure sensation with radiation to the sides. The patient had similar pain in the past and was prescribed Pepcid, which did not help. The pain was associated with hiccups, nausea, vomiting, and retching. The patient denied fever and diarrhea. The patient's girlfriend who was present at the bedside stated that the patient complained of diaphoresis and fatigue and taking showers all the time to relieve the sweating. The patient denied pruritus.

In the emergency department, the patient was found to have multiple electrolyte abnormalities and acute kidney injury. On the physical exam, the patient was afebrile. The vital signs were heart rate 115 beats per minute (bpm), respiratory rate 18 breaths per minute, and blood pressure 178/126. The patient was in mild distress from hiccups. There was oral thrush and dry oral mucosa. The abdomen was soft, non-tender to palpation, with normal bowel sounds, without guarding or rebound. The rest of the physical exam was unremarkable.

Laboratory evaluation revealed that the white blood cell count was 35.3, hemoglobin 17.3, hematocrit 49.5, and platelets 253. The serum amylase was 122 and lipase 57. As far as the patient's electrolytes, sodium was 128, potassium 3.2, and chloride 89. The patient's bicarbonate was 22, blood urea nitrogen (BUN) 47, creatinine 3.5, and glucose 107. The patient's urinalysis was unremarkable. The electrocardiogram (EKG) demonstrated sinus rhythm with occasional sinus arrhythmia.

The patient was admitted to the hospital with epigastric pain. The differential diagnosis included gastroesophageal reflux disease (GERD), gastritis versus other etiology. The patient was also diagnosed with electrolyte abnormalities including hypokalemia and hyponatremia as well as acute kidney injury. It was also mentioned that the patient had chronic leukocytosis. During the hospital stay, the patient's abdominal pain and hiccups resolved. As a result of the treatment with intravenous fluids the acute kidney injury significantly improved, and the serum creatinine came down from 3.6 to 1.5. 

Because of persistent leukocytosis, the patient had the following laboratory tests including erythrocyte sedimentation rate (ESR), hepatitis B and serologies, procalcitonin, rheumatoid factor, and component 3 (C-3). All these tests were normal, although component 4 (C-4) was elevated. The patient was seen by a hematologist who recommended additional laboratory evaluation, which was performed. However, laboratory study results were not available at the time of discharge. The patient was discharged with a recommendation to follow up with a hematologist.

The requested health service/treatment of inpatient stay was not medically necessary for this patient. The patient's condition and the complexity of services provided did not justify admission to the inpatient level of care. A threefold increase in serum creatinine is the criterion that would justify admission at the inpatient level of care. However, the patient's baseline creatinine was unknown, therefore, it was impossible to determine if the patient had a threefold rise in serum creatinine from baseline. Furthermore, the creatinine almost normalized and electrolyte abnormalities significantly improved after the administration of intravenous fluids within the first 24 hours of the hospitalization. The patient was able to tolerate a diet and did not require further administration of intravenous fluids.