Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Infectious Disease-Viral Infection. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission for medical necessity. 
The denial was overturned. 

The patient is a female with a past medical history (HX) of hypertension (HTN), and chronic kidney disease (CKD) who presented to the emergency department (ED) with complaints of (c/o) chest pain and shortness of breath. The patient had recently been found to have coronavirus 2019 (COVID-19) pneumonia (PNA). She reported a productive cough of sputum now yellowing as well as vomiting. In the ED, her vital signs were a temperature (T) at 98.7, heart rate (HR) was 84, respiratory rate (RR) was 18, pulse oxygen (O2) saturation was 98%, and blood pressure (BP) was 117/79.
Her labs noted a sodium (Na) at 138, potassium (K) was 5.8, carbon dioxide (CO2) was 14.7, blood urea nitrogen (BUN) was 47, Creatinine was 2.74, white blood cell count (WBC) was 4.71, hemoglobin (Hgb) was 8.8, and platelets (Plt) were 191. Baseline Creatinine was last noted to be 1.9. Her electrocardiogram (EKG) showed slight peaking of T waves.
The patient was started on dexamethasone, azithromycin, and ceftriaxone as well as Low Molecular Weight Heparin. She was admitted for management of acute on chronic kidney injury, hyperkalemia, metabolic acidosis, and vomiting. She was treated additionally with intravenous fluids (IVF) and her hyperkalemia was treated with insulin, calcium gluconate, Lasix and Lokelma.
On hospital day 2, the patient's CO2 improved to 15.8, Creatinine was 2.62, K was 5.7, ferritin was 3156, and C-reactive protein (CRP) was 77. The patient was seen by nephrology with acute kidney injury (AKI) presumably due to viral syndrome secondary to COVID-19. The patient was not a candidate for remdesivir due to a reduced glomerular filtration rate (GFR).  Her nausea and vomiting improved and she was able to tolerate by mouth (PO). Her K improved to 5.1 at discharge (d/c), and Creatinine stabilized at 2.6. She was discharged home. 
At issue is the medical necessity of the Inpatient Stay.

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

The requested health service/treatment of Inpatient Stay was medically necessary for this patient.
The patient was hospitalized with complications of a COVID-19 infection. [1] She presented with significant gastrointestinal symptoms and acute kidney injury complicated by hyperkalemia. She was noted to have electrocardiogram (EKG) changes consistent with cardiac toxicity due to hyperkalemia. She required acute inpatient level care for treatment of complications of COVID-19 and hyperkalemia. The early course of COVID-19 infections is known to be the most critical with rapid clinical change and decline in days 5-7. [2] It would put the patient at unnecessary risk of morbidity and mortality to not provide inpatient care given her COVID-19 infection, potential cardiac toxicity, acidosis, and potential to no longer be able to compromise from a respiratory standpoint and further risk of acute worsening hyperkalemia due to her acidosis. [3]
Therefore, the Inpatient level of care was medically necessary for this patient.