Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Grave's disease
Treatment: Inpatient hospital
The insurer denied the inpatient hospital admission.
The health plan's determination is upheld. 

The patient is a male with a past medical history of Grave's disease, who was admitted for generalized malaise and cough. Review of system was positive for weight loss, palpitations, and non-compliance with home medications.

The patient was afebrile (temp of 99F [degrees Fahrenheit]), described as normal male in no acute distress. His blood pressure was 144/83, pulse rate of 111, and oxygen saturation of 90% (percent). Physical examination on admission was remarkable for 1+ pitting edema on the lower extremities.

Laboratory evaluation demonstrated a sodium of 135, potassium of 3.3, chloride of 98, carbon dioxide (CO2) of 27, blood urea nitrogen (BUN) of 9.3, creatinine of 0.63, white blood cell (WBC) count of 4.7, Hgb (hemoglobin) of 14.1, Hematocrit (HCT) of 40.9, platelet of 192, D-dimer was 284. Urine analysis was negative. Chest x-ray was negative.
The patient was admitted for Grave's disease and to rule out thyroid storm.

The the inpatient hospital admission was not medically necessary.

The documentation does not support an inpatient level of care. Although the patient had tachycardia, the patient had hemodynamic stability, normal mentation, and no evidence of arrhythmia. The patient was admitted for severe hyperthyroidism due to non-compliance and possible impending thyroid storm. The treatment entailed observation on telemetry and medication adjustment. Therefore, the care could have been rendered at a lower level of care.

Thyroid storm (also known as thyroid or thyrotoxic crisis) is an uncommon condition reflecting an extreme physiological state within the spectrum of thyrotoxicosis. The condition is rare; however, mortality rates are high and may approach 10-20%. In many cases, the classical signs and symptoms of a thyrotoxic state may be seen, but that does not necessarily mean that the patient has thyroid storm. The scoring system suggested by Burch and Wartofsky illustrates the typical features of end organ dysfunction that may be seen when thyrotoxicosis is severe enough as to be termed thyroid storm. In this case, the patient's Burch and Wartofsky was 35 and showed improvement with treatment. Additionally, Fever is almost universal (> [greater than] 39C [Celsius] or 102F) and when present in an unwell patient with known thyrotoxicosis, should prompt immediate consideration of thyroid storm. Associated profuse sweating contributes to excessive insensible water and electrolyte loss leading to dehydration. Cardiac decompensation, usually in the context of high-output cardiac failure, is manifested as evidence of peripheral edema or pulmonary congestion with respiratory compromise when severe. Tachyarrhythmias are common and usually atrial in origin, unless there is a predisposition to ventricular arrhythmias secondary to primary cardiac disease. Neurological dysfunction may be severe enough as to cause profound delirium or psychosis. Liver dysfunction, secondary to either the presence of cardiac failure with hepatic congestion or hypoperfusion, or a direct effect of the excess thyroid hormone itself, is characterized by abnormal liver function biochemistry. Jaundice may be noted, and abdominal pain is often seen accompanied by nausea and vomiting, and diarrhea. The patient did not demonstrate any of the above signs/symptoms to fulfill the clinical criteria for thyroid storm.