Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypovolemia, acute kidney injury
Treatment: Full hospital admission
The insurer denied coverage for full hospital admission
The denial is overturned

The patient is an adult with a past medical history which includes hyperlipidemia and hypertension. The patient presented to the Emergency Room (ER) after having a witnessed syncopal episode in urgent care. The patient had been feeling weak, fatigued, and lightheaded for a few days. The patient took a dose of Tamiflu on the morning of admission. The patient was hypotensive upon arrival to the ER. The patient remained hypotensive after intravenous (IV) fluids and other conservative treatment. Systolic blood pressures documented in the ER ranged from 77 to 102.

The patient's Creatinine was elevated at 1.56 with glomerular filtration rate (GFR) of 51, blood glucose was minimally elevated at 115, aspartate aminotransferase (AST) was trivially elevated at 38 (normal less than 36). Lab work was otherwise unremarkable, including normal troponin and normal white cell count, although the differential was neutrophil predominant. The patient tested positive for influenza A. The chest x-ray (CXR) and electrocardiogram (EKG) were reassuring. The patient's home medications included only metoprolol tartrate and olmesartan.

The patient's condition was considered critical, due to hypotension, acute kidney injury, syncope, and influenza.

Per the admission History and Physical, the plan was for hydration, trending labs, monitoring blood pressure, and continuation of Tamiflu.

The guideline was submitted for direct review. In it, admission is indicated for "1 or more of the following:" Hemodynamic instability. dehydration that is severe or persistent, altered mental status that is severe or persistent, acute renal failure (stage 3 acute kidney injury), acute kidney injury (stage 2). MCG indicates that the "Goal Length of Stay" for this condition is 2 days. 

The hospital appealer referenced MCG General Admission Criteria (CG-GAC). Admission is indicated by the need for any one (or more) of the following: Continuous IV fluids, continuous cardiac monitoring, serial lab studies.

After a witnessed syncopal episode in an acute-care medical setting, the patient was found to be severely and persistently hypotensive, with evidence of acute renal injury. The patient met the requirements for admission.

The degree of renal failure is graded based on GFR, which in this case was 51, consistent with grade 3 renal failure according to the 2012 Kidney Disease Improving Global Outcomes Chronic Kidney Disease (KDIGO CKD) classification. As indicated, this was presumed to be secondary to hypovolemia associated with Influenza A, and it did respond to hydration with continuous IV fluids.

The concept of hemodynamic instability suggests inadequate perfusion from any of a number of causes, and describes a continuum that includes shock, with its typical etiologies. The relevant varieties in this case included distributive (typically due to infection) and hypovolemic (inadequate volume) causes. Typical findings from hemodynamic instability include low blood pressure, and common symptoms include fainting, dizziness, and tiredness, among many. 

Inpatient hospitalization was appropriate for treating the patient's influenza, syncope, and renal failure.

The inpatient hospitalization was medically necessary for the patient. The patient was acutely and critically ill. The patient was hemodynamically unstable, severely dehydrated, had a severe alteration in mental status in the form of syncope (loss of consciousness), and had stage 3 acute kidney injury. These are the criteria noted above in Milliman Care Guidelines (MCG) 26th Edition Viral Illness, Acute.

Based on the above, the insurer's denial must be overturned. 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 the full hospital admission is substantiated.