Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute Kidney Failure.
Treatment: Inpatient Hospital.

The health plan denied the inpatient hospital stay. The health plan's determination is overturned.

This is the case of a female with a past medical history of anemia and obesity who presented to the emergency department with back pain, fevers, nausea/vomiting, dysuria, weakness, and dizziness.`
Labs resulted with a white blood cell count (WBC) of 10.38, a Hemoglobin (HGB) of 9.2, platelets of 173, a sodium of 123, a potassium of 3.9, a blood urea nitrogen (BUN) of 45, a creatinine of 2.95, an aspartate aminotransferase (AST) of 46, an alanine aminotransferase (ALT) of 12, an alkaline phosphatase of 263, a total bilirubin of 0.7, and an international normalized ratio (INR) of 1.39. Urinalysis was positive for leukocyte esterase, WBC 26-50, and few bacteria. The patient was brought into the hospital with concerns for acute kidney injury, hyponatremia, anemia, acute low back pain, and urinary tract infection, and with plans for checking stool for occult blood, intravenous (IV) fluids, renal ultrasound, Ceftriaxone, follow up urine cultures, a computed tomography (CT) of the abdomen and pelvis, nephrology consult, and Tylenol and Oxycodone as needed.
The CT of the abdomen and pelvis noted cirrhosis, diffuse gallbladder wall thickening, and no lumbar spine fracture or traumatic spondylolisthesis.
The day after admission, the patient remained hemodynamically stable. She had ongoing back and flank pain in addition to nausea. WBC was 7.34 with a HGB of 8.8, a sodium of 123, and a creatinine of 2.44. Renal ultrasound showed non-specific symmetric increased vascularity and size as well mild heterogeneity on the left when compared to the right without evidence of obstruction or hydronephrosis. Concern was for acute renal failure and urinalysis. The patient was seen by nephrology with plans to continue IV fluids and follow up labs. The patient was otherwise continued on Ceftriaxone.
The following day, the patient was hemodynamically stable without fever, hypotension, tachycardia, or tachypnea. She was feeling better. Her sodium was 127 and creatinine was 1.62. Urine culture resulted with E. coli. Concern was for ongoing hyponatremia and urinary tract infection with possible pyelonephritis with plans for ongoing IV fluids and Ceftriaxone and referral to gastroenterology as an outpatient for her cirrhosis.
The following day, the patient remained hemodynamically stable. Follow up creatinine was 1.45. The patient was seen by infectious disease with an assessment that she had completed 4 days of Ceftriaxone and could be discharged on Cefpodoxime for 10 days.
The issue in question is whether care at the inpatient level of care was medically necessary. 

The health plan's determination of medical necessity is overturned, in whole.

Yes, as noted above, inpatient stay was medically necessary for this patient immunocompromised from her cirrhosis presenting with a urinary tract infection and concomitant renal failure.
This is a patient who presented with frank renal failure with creatinine 2.95 in the setting of no known renal disease with concern for concomitant urinary tract infection as well as pyelonephritis. She was at risk for worsening renal failure as well as infection, particularly in the setting of cirrhosis which is an immunocompromising condition. She required IV fluids, IV antibiotics, and close monitoring of her renal function, and follow up of her cultures to ensure antibiotics were tailored appropriately with her immunocompromised state. Inpatient level of care was appropriate for this patient presenting with acute renal failure, urinary tract infection, and concern for pyelonephritis in the setting of cirrhosis.