Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Peritonitis
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is overturned.

The insurer has denied coverage for inpatient hospital services. In their Final Adverse Determination letter, they write that the medical records received were reviewed and the patient with a past medical history of congenital kidney failure and gastrostomy tube dependence presented with fever. The patient was afebrile and hemodynamically stable upon admission. There is no documentation of an adverse change in clinical status, intensity of services, or new condition supporting change to an inpatient level of care after the observation period.

The hospital is appealing. In an appeal letter, it states that the patient was admitted on an inpatient basis for the urgent management of this patient who was noted with tachycardia, fever and was a high risk for sepsis due to indwelling catheter for peritoneal dialysis requiring close monitoring that could not be safely managed in a lower level of hospital care or in an outpatient setting. The patient was admitted to the pediatric unit with a diagnosis of fever. The patient received peritoneal dialysis around midnight while continuing on (intravenous) IV Vancomycin, IV cefepime and IV fluconazole, all renally dosed. The patient was closely monitored throughout the hospitalization until the patient was medically optimized.

The patient has a history of end-stage renal disease managed on peritoneal dialysis. The patient presented with a history of fever at home and due to a high risk for infection, especially peritonitis, the patient was admitted for inpatient management and antibiotic therapy pending results of the peritoneal fluid culture.

The patient received standard of care for the management of fever in an immunocompromised infant receiving peritoneal dialysis at risk for peritonitis which would disrupt life-saving peritoneal dialysis (PD). Peritonitis is a common and severe complication in peritoneal dialysis. Peritonitis remains a frequent complication of peritoneal dialysis in children and is the most common reason for technique failure. Risk factors for infection include young age (Chadha V et al), highlighting the increased risk for this infant presenting with a fever. 

According to Szeto CC et al, when a patient on PD (peritoneal dialysis) presents with clinical features compatible with PD-associated peritonitis, like the patient in review, empirical antibiotic therapy, with coverage of both Gram-positive and Gram-negative organisms (including Pseudomonas species), should be started once the appropriate microbiologic specimens have been obtained. Once the PD effluent Gram stain or culture and sensitivity results are available, antibiotic therapy can be adjusted accordingly.

According to Al Sahlawi, M., Bargman, J. M., & Perl, J., "Peritonitis is a common complication of peritoneal dialysis that is associated with substantial morbidity and mortality. Peritonitis increases treatment costs and hospitalization events and is the most common reason for transfer to hemodialysis. Although there is much focus on preventing peritoneal dialysis-associated peritonitis, equally as important is appropriate management to minimize the morbidity of a peritonitis episode when it has occurred. Despite the presence of international guidelines on peritonitis treatment, the evidence base to support optimal peritonitis treatment practices is lacking, leaving the practitioner to rely on clinical experience and extrapolate from across other infection treatment practices."                                                         

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient hospital services is substantiated.