Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Painful Bilateral Leg Swelling and Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a woman with a history of bipolar disorder, diabetes mellitus and hypertension. She presented to the hospital with bilateral lower extremity swelling and pain of several months duration. She was unable to provide a satisfactory history due to being tangential, impulsive and pressured in her speech. However, her thought content did not include suicidal or homicidal ideation. Further, documentation does not include any mention of hallucinations, agitation, violent behavior or delusional behavior / thoughts.

The patient had normal vital signs. Her examination revealed bilateral lower extremity swelling. Labs demonstrated normal CBC (complete blood count) with anemia, normocytic, and normal liver function tests with albumin of 4.5. Glucose level, Anion gap, bicarbonate, electrolyte values and troponin were normal. CPK (creatine phosphokinase) was modestly elevated to 500 or so units. She had a creatinine of 1.47 mg/dL (milligrams per deciliter). There was reported inability to urinate, but no urine output and intake were documented.

The patient had a normal x-ray of the chest, normal BNP (brain natriuretic peptide) value, and normal ECG (electrocardiogram). She was given IV (intravenous) Haldol, IV (intravenous) fluids and hospitalized with plan for inpatient consultation with psychiatry. The patient then decided to leave against medical advice.

The health plan denied inpatient hospitalization since the patient did not have any acute alterations, no intractable symptoms, normal hemodynamic status and normal vital signs. No clinical instability of acute or chronic problems were identified in the documentation. No medical condition requiring acute intervention was identified in the medical record.

The hospital has submitted an appeal document that indicates a retrospective review is compromised by hindsight and distance. The decision to admit patient to inpatient status was made by a practitioner after considering the patient's overall condition.

No, the Inpatient admission was not medically necessary.
The patient had normal vital signs, chronic and long standing edema without signs of infection, normal albumin level, arguing against renal disease causing edema, normal BNP (brain natriuretic peptide) making heart disease or congestive heart failure very unlikely, with lack of pulmonary edema or dyspnea or elevated jugular venous pressure. The most likely explanation for the patient's edema was local venous congestion and venous insufficiency. There was no asymmetry in the edema noted and no inflammation or documented Homan's sign with a low Well's score, making deep venous thrombosis unlikely also. The patient reported low urine output but did not have any documentation of urine output and her baseline creatinine was not known.

According to the KDIGO (Kidney Disease Improving Global Outcomes) guidelines, a rise in creatinine of 1.5 times baseline within one week or 0.3 mg/dL (milligrams per deciliter) within 48 hours or urine output less than 0.5 ml/kg (milligrams per kilogram)/hour is required for diagnosis of renal failure. None of these are documented to have been present. Further, there was no sign of systemic fluid overload, pleuritis, uremia, acid-base abnormality, low anion gap, lactic acidosis, low bicarbonate or electrolyte abnormality to support a clinical diagnosis of acute kidney injury.

The patient was not a threat to herself or others as evidenced by lack of violent behavior, agitated behavior, and lack of suicidal and homicidal ideation. There were no hallucinations or delusions documented.

Thus, the patient's medical and psychiatric conditions were not an immediate threat to the patient or others. Her physiologic impairments do not suggest any acute condition.

As such, inpatient services were not needed due to lack of acuity and severity. The anticipated interventions at the time of admission were consult to psychiatry, Haldol once IV (intravenous) and IV (intravenous) fluids - these interventions can readily be accomplished in an observation setting.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.