Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lupus
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is overturned.

The patient is a teenage female with medical history significant for systemic lupus erythematosus (SLE) with recent admission for trial of rituximab to treat lupus-related joint pain. She presented to the emergency department with one-day history of 
generalized body pains worst in the neck, shoulders, and hips. She had been seen in the emergency department the day prior for right face swelling, along with bilateral hand and foot pain, and was discharged home with ibuprofen. She had no fevers, headaches, or other constitutional symptoms except for decreased appetite. The facial swelling had resolved. Treatment at home with acetaminophen and ibuprofen was ineffective. Her pain was worse than pain from lupus flares in the past. The patient's vital signs included temperature 36.9, heart rate 89, respiratory rate 21, and blood pressure 126/81. Examination was significant for visible discomfort/pain, moist mucous membranes, neck with full range of motion, no Kernig's or Brudzinski's signs, clear lungs, regular heart rate and rhythm, benign abdomen, good perfusion, and able to ambulate with some difficulty due to pain. Laboratory evaluation was significant for white blood cells 3.7K (thousand) with 91.9%(percent) neutrophils, hemoglobin 10.5, platelets 445K (thousand), C-reactive protein 21.7, creatine kinase 308, albumin 2.8, AST (aspartate aminotransferase) 69, ALT (alanine aminotransferase) 16, CO2 (carbon dioxide) 20.2, ferritin 212, complement C3 (complement component 3) 40, complement C4 (complement component 4) 6, respiratory pathogen panel negative, CSF (cerebrospinal fluid) protein 19.5, and glucose 50.0, with negative meningoencephalitis panel, cultures negative. Rheumatology consultation was sought with recommendations to administer intravenous fluids, Toradol, follow-up labs for infectious etiology, treat with steroid burst following lumbar puncture. Her pain improved somewhat following Toradol, but with persistent spine, shoulder, 
and hip pain. Because of her history of being immunocompromised, there was concern for atypical presentation of meningitis. Computed tomography (CT) scan was performed (negative) followed by lumbar puncture with conscious sedation (Versed). She was treated with meningitis dosing of ceftriaxone, prednisone 40 milligrams for 10 days, and was admitted for ongoing monitoring. Admission orders included prednisone 40 milligrams daily for 10 days, intravenous Tylenol and Toradol round-the-clock, continued home lupus medications (Paquenil, Cellcept), transition to oral pain medications as tolerated, regular diet, maintenance intravenous fluids, consideration for Miralax. The patient did well overnight, with pain decreasing to 2/10 treated with acetaminophen and ibuprofen. The intravenous fluids were discontinued, and she was able to tolerate adequate fluids by mouth. Incidentally, she was noted to be hypertensive with microscopic hematuria. Rheumatology consultant was aware with plans for nephrology follow-up. She was cleared for discharge home the next day to complete a 10-day course of prednisone.

The inpatient admission was medically necessary.

This female child presented following rituximab trial with new-onset severe joint pain in her shoulders, hips, and neck, different from her usual lupus flares. Because of her immunocompromised state, there was concern for atypical presentation of meningitis, prompting CT (computed tomography) imaging and lumbar puncture. She had failed treatment at home with 
acetaminophen and ibuprofen. Rheumatology consultation included recommendations for parenteral Tylenol and Toradol around-the-clock, along with intravenous hydration and steroid burst. She responded well to this combination of therapies, with improvement in her pain sufficient to discharge home. Given the nature of her illness, her failed outpatient treatment, and recurrent visits to the emergency department, acute inpatient admission was medically necessary and appropriate.