Appeal type: Medical necessity
Decision: Upheld

Diagnosis: End Stage Renal Disease (ESRD)

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
This is an adult female with a history of hypertension, Type 1 diabetes, gastroparesis, End Stage Renal Disease (ESRD) on hemodialysis, congestive heart failure (CHF) with Automatic Implantable Cardioverter Defibrillator (AICD), ascites, hypothyroidism, seizure disorder, ventral hernia who presented to emergency department (ED) with suspected purulent drainage from the Arterial - Venous fistula (AVF) site. In the ED the patient was afebrile with stable vitals. The fistula site was erythematous with questionable purulent drainage. Abdomen distention also noted. Labs: Blood Urea Nitrogen / Creatinine (BUN/Cr) = 34/5.41, Glomerular Filtration Rate (GFR) = 10, Sodium (Na+) = 132, glucose = 379. Lactic Acid = 3.7 Blood cultures sent x 2. Patient received multiple pain medication doses parenterally, nephrology consult noted no pus at AVF at the time of their Exam but there was erythema. Nephrology indicated no need for catheter hemodialysis, as no signs of volume overload; they covered with broad spectrum antibiotics. The patient was admitted and was treated for a local cellulitis; she also had an abdominal paracentesis. Patient improved, was stable for discharge home with outpatient follow-up. The insurer has denied coverage for the hospital admission as not medically necessary. The appeal on behalf of the hospital is noted and read in detail. 

Per Milliman Care Guidelines (MCG) Health (27th  Edition) Renal Failure-Chronic. Patient fails to meet clinical indications for admission to inpatient care. These include hemodynamic instability, evidence of CHF, altered mental status - severe and persistent, urgent need for dialysis, electrolyte imbalance, etc., evidence of sepsis, etc.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient hospital admission is not substantiated.
Diagnosis: End Stage Renal Disease (ESRD)

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
This is an adult female with a history of hypertension, Type 1 diabetes, gastroparesis, End Stage Renal Disease (ESRD) on hemodialysis, congestive heart failure (CHF) with Automatic Implantable Cardioverter Defibrillator (AICD), ascites, hypothyroidism, seizure disorder, ventral hernia who presented to emergency department (ED) with suspected purulent drainage from the Arterial - Venous fistula (AVF) site. In the ED the patient was afebrile with stable vitals. The fistula site was erythematous with questionable purulent drainage. Abdomen distention also noted. Labs: Blood Urea Nitrogen / Creatinine (BUN/Cr) = 34/5.41, Glomerular Filtration Rate (GFR) = 10, Sodium (Na+) = 132, glucose = 379. Lactic Acid = 3.7 Blood cultures sent x 2. Patient received multiple pain medication doses parenterally, nephrology consult noted no pus at AVF at the time of their Exam but there was erythema. Nephrology indicated no need for catheter hemodialysis, as no signs of volume overload; they covered with broad spectrum antibiotics. The patient was admitted and was treated for a local cellulitis; she also had an abdominal paracentesis. Patient improved, was stable for discharge home with outpatient follow-up. The insurer has denied coverage for the hospital admission as not medically necessary. The appeal on behalf of the hospital is noted and read in detail. 

Per Milliman Care Guidelines (MCG) Health (27th  Edition) Renal Failure-Chronic. Patient fails to meet clinical indications for admission to inpatient care. These include hemodynamic instability, evidence of CHF, altered mental status - severe and persistent, urgent need for dialysis, electrolyte imbalance, etc., evidence of sepsis, etc.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient hospital admission is not substantiated.