Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay
The determination is upheld.

The patient has a history of hypertension, hyperlipidemia, and diabetes, as well as coronary artery disease, who presented to the hospital for abnormal lab results. She followed with a hematologist secondary to anemia and was advised to go to the emergency department based on the lab results. The patient was asymptomatic with the laboratory abnormalities, was described as awake and alert, and denied any chest pain, shortness of breath, nausea, or vomiting. She had baseline renal insufficiency with a creatinine of 2.5. On exam, the patient did not appear to be in general distress. The cardiopulmonary exam was unremarkable, and no neurologic deficits were noted. The vital signs included a temperature of 36.9 degrees Celsius, a heart rate of 61, and a blood pressure of 184/76. Respirations were 16.
Repeat labs in the emergency department (ED) show a creatinine of 3.53, blood urea nitrogen (BUN) of 80.3, potassium of 5.9, and bicarbonate of 21. The urinalysis showed clear urine, with trace glucose negative nitrites and leukocyte esterase. A renal ultrasound was obtained, showing no hydronephrosis, no stones, and no post-void residual. The principal admitting diagnoses were acute renal failure and hyperkalemia. The patient was given Kayexalate and nephrology was consulted for an evaluation. The patient's hemoglobin was 8.6, and she was already taking multivitamin and iron supplementation. Coronovirus disease testing was negative.
Nephrology assessed the patient and noted the patient had a baseline serum creatinine around 2. Recently her dose of losartan had been increased to 100 milligrams (mg) for elevated blood pressures. The nephrologist concluded that the patient had an acute kidney injury related to hemodynamic changes from losartan and diuretics. They provided the patient with a half-normal saline infusion at 60 milliliters per hour (mL/h) for 24 hours. The urine protein creatinine was 6.1 grams. They concluded that the proteinuria was likely caused by diabetic nephropathy and hypertensive nephrosclerosis. They held the patient's losartan and hydrochlorothiazide. Repeat labs were ordered for the following day.
The next day, a cardiology consultation was requested for hypertension management. The patient's blood pressure was 134/69, with a heart rate of 71 and a temperature of 36.7 degrees. The cardiopulmonary exam was fairly unremarkable. Repeat labs show a potassium 5, bicarbonate of 21, and creatinine of 3.62. The hemoglobin decreased to 7.8, with a mean corpuscular volume (MCV) of 87. The cardiologist did not recommend any changes or further cardiac testing, as the patient had recent pacemaker interrogation, an echocardiogram, and stress test. They stated the patient was stable from a cardiovascular standpoint. The medical team also assessed the patient and reported that the patient was slightly overloaded with otherwise stable vital signs. Therefore, the rate of IV was reduced to 40 milliliters per hour (mL/h).
The medicine team requested a consultation from hematology for evaluation of anemia. The hemoglobin was 7.8. The hematologist concluded that the patient had adequate B12 levels and normal ferritin levels. They ordered serum protein electrophoresis (SPEP), reticulocyte count, haptoglobin levels, direct Coombs test, lactate dehydrogenase (LDH), and stool occult blood testing.
The next day, the patient was doing well. The vital signs appeared stable. The creatinine was down to 3.3; the hemoglobin remained stable at 7.9.
The next day, the patient reported feeling fine. The exam was fairly unremarkable. The laboratory studies revealed a potassium of 5.3, creatinine of 3.29, and BUN of 62. The hemoglobin was registered at 8 grams per deciliter (g/dL). The nephrologist note stated that the patient's serum creatinine was unchanged and stable. They recommended adjusting the medications per the glomerular filtration rate (GFR) and a low potassium diet to be followed.
The patient's vital signs were a temperature of 36.9 degrees, heart rate of 69, blood pressure 159/63, and normal oxygen saturation. The final set of repeat labs were relatively unchanged from the day before, and the potassium was slightly lower at 4.8.
Outpatient nephrology follow-up was set up. The patient was started on Procrit supplementation while in the hospital and was to follow up in the outpatient setting with hematology to monitor the anemia further.
The issue for review is whether an inpatient stay was medically necessary for this patient.
The requested health service/treatment of inpatient stay for the stated dates was not medically necessary for this patient.
The patient had chronic kidney disease stage III, with a baseline creatinine of around 2.5. She presented to the hospital with an increase in the serum creatinine to 3.53. The creatinine increase was attributed to an increased dose of losartan, which is a known side effect. The patient was asymptomatic and experienced no evidence of hypoxemia or uremia to require renal replacement therapy. The creatinine was less than 4, and there was no evidence of a threefold increase from baseline in the creatinine level. The patient was not anuric; the documentation showed a stable urinary output. The patient only had mild hyperkalemia, which was rapidly corrected within the observation time frame. There were no peaked T waves noted on electrocardiogram (EKG), and there were no concerning cardiac arrhythmias present. Hyperkalemia with significant EKG changes typically warrants inpatient stay, which was not the case in this situation. There was no evidence of vasculitis, causing renal dysfunction such as Wegener's or Goodpasture syndrome, which would require immediate attention with plasmapheresis, and advanced therapies. The patient's clinical status was stable, and the primary modality of treatment was gentle intravenous (IV) fluids. Based on medical necessity, this type of presentation could be managed at a lower level of care. The Milliman Criteria for acute renal failure M-326 also support the conclusion that clinical indications for inpatient admission were not satisfied.
In addition, the titration of blood pressure medications is typically not indicated in the inpatient setting, unless truly accelerated hypertension is present. The documentation failed to demonstrate such a condition in this presentation. An anemia work-up is an outpatient evaluation and does not require inpatient hospitalization.