Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rule out tuberculosis. 

Treatment: Inpatient services. 

The insurer denied coverage for the inpatient services. 

The denial is upheld. 

This is a male patient with immunocompromised status who is non-compliant with his medications. Other medical issues include posttraumatic stress disorder (PTSD), depression, and bipolar disorder. The patient presented to the Emergency Department (ED) with complaints of cough, weight loss, night sweats and dysuria. The patient reported some productive cough, night sweats and 30 pound weight loss over past several months. The patient noted a pigmented rash under his right (R) eye and also complained of some burning. The patient also had a vesicular rash over the elbow.

Vital Signs (V/S) in the ED were temperature (T) 97.7, heart rate (HR) 92, respiratory rate (RR) 19, blood pressure (BP) 120/92 and oxygen saturation (O2) saturations 100%. The patient was in no acute distress (NAD). Lungs were clear. The patient was noted to be cachectic. Lichenified rash is noted below R eye and some vesicular rash noted near elbow.

The patient was admitted to rule out tuberculosis (TB) even though the medical doctor's (MD) admitting note states TB is low suspicion.

As per History & Physical (H&P) T 98.3F, HR 86, RR 20, BP 114/82 and O2 saturations 98%. The patient was in NAD. Lungs were clear. The patient was awake and alert. The patient had a non-focal neuro exam.

White blood cell (WBC) count was normal. Hemoglobin (Hb) 11.6, electrolytes essentially normal, urinalysis (UA) was positive for leukocyte esterase (LE) and WBC 21-25 / high power field (HPF). Chest x-ray showed no acute infiltrate. Cluster of differentiation 4 (CD4) was <10. Viral Load was > 100.

The patient was started on Levaquin for urinary tract infection (UTI). Quantiferon Test was negative. Acid-fast bacillus (AFB) was negative. 

The patient was seen by Psychiatry. He expressed some auditory hallucinations. They felt that he was expressing some Psychosis; PTSD with Psychosis Features. They recommended oral (PO) Zyprexa.

The patient was seen by Dermatology for biopsy of his skin lesions.

This patient was admitted to medicine for five days and eventually transferred to Psychiatry.

This patient did not need acute inpatient hospitalization in Medicine. His medical conditions were chronic in nature. The patient was afebrile, hemodynamically (HD) stable. Labs were essentially unremarkable for acute changes requiring inpatient hospitalization. Suspicion for TB was low. His skin rashes were chronic. UTI/Cystitis was mild and could have been treated in an outpatient setting with PO antibiotics. The patient could have been evaluated by Dermatology in an outpatient setting and punch biopsy (Bx), if needed, could have been done in the same setting without need for acute inpatient hospitalization. This patient could have been placed in Observation status while diagnostic testing and treatment initiated. TB could have been ruled out (if deemed necessary) by 3 sputum samples tested 8 hours apart. Observation period could be for up to 48 hours if necessary. This patient was chronically ill and did not need acute inpatient hospitalization. If admission was deemed necessary for psychiatric reasons then he should have been admitted to a Psychiatry Bed. 

The healthcare plan acted reasonably and with sound medical judgment in the best interest of the patient. An inpatient stay was not medically necessary.

The insurer's denial of coverage for the inpatient services is upheld. Medical necessity is not substantiated.