Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Kidney Injury.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient was brought to the hospital with complaints of frequent urination and generalized weakness. The patient has a past medical history of diabetes with diabetic nephropathy, asthma, and substance abuse, including crack cocaine. The patient was unable to state how long the urinary symptoms were present. She did not recall any of her medications and stated she has recurrent vaginal discharge. She was also complaining of constipation, with intermittent blood in the stool, with the last bowel movement between 2 and 3 days ago. She reported to the emergency department (ED) physician that she had dizziness and weakness for the past year. She used cocaine 3 days prior.
Vital signs on admission included a temperature of 98.2 degrees Fahrenheit, pulse rate of 110, blood pressure 121/65, and respirations of 20. Oxygen saturations were 100%. On exam, she was alert and oriented times (x) 3, with normal heart sounds, decreased breath sounds bilaterally, and mild end-expiratory wheezing. She was described as not tachypneic on the exam. Neurologically, she had an ataxic gait, with 4 out of 5 strength in the upper extremity on the left and lower extremity on the right. The ED obtained labs, including a complete blood count (CBC) showing a hemoglobin of 7.4, mild leukocytosis, drug screen positive for cocaine, and hyperglycemia without diabetic ketoacidosis (DKA). A chest x-ray did not show any infiltrates, and a computed tomography (CT) scan of the head was negative. The chemistry panel showed a sodium of 134 with potassium of 5. The creatinine was 1.3 with a blood urea nitrogen (BUN) of 21. The alkaline phosphatase was slightly elevated at 165. A twelve-lead electrocardiogram (EKG) showed normal sinus rhythm without ST-segment(the line on the electrocardiogram that begins with the end of the QRS complex and ends at the beginning of the T wave) elevations.
The patient was admitted to the hospital with a diagnosis of acute kidney injury, with a baseline creatinine from 0.9-1. The medical team ordered an abdominal ultrasound, kidney ureter bladder (KUB) and started intravenous (IV) fluids. They also ordered monitoring the urine output. The patient had acute, chronic hypercalcemia on the labs, so a parathyroid hormone (PTH) level and vitamin D levels were checked. Regarding the microcytic anemia, the patient had no active bleeding and was hemodynamically stable; an iron profile was obtained.
The medical team reassessed the patient and reported no events overnight; the patient was afebrile and hemodynamically stable. The patient requested a brain magnetic resonance imaging (MRI) scan because she felt unsteady on her feet. The vital signs appeared stable. Repeat lab results were not available; the medical team continued IV fluid hydration and started the patient on Metformin and Lantus. The patient had not taken any of her medications for many months. It appears that an ultrasound of the neck and thyroid had also been ordered, given the hypercalcemia, which showed multiple thyroid nodules with no calcifications. An ultrasound of the abdomen showed no hydronephrosis.
The next day, repeat lab results were available, the hemoglobin was unchanged at 7.2. The creatinine was 1.36, with stable electrolytes. The medical team concluded that this was the patient's likely new baseline. They decided to pursue IV fluids for an additional day. They ordered a brain MRI to assess the cerebellum. The medical team documented if an MRI was negative, anticipate discharge home. The patient's blood glucose was registered at 435, and she was given 6 units of Humalog per sliding scale. At 5 AM the next morning, the patient was observed crying. She signed herself out against medical advice and left the hospital.
At issue is the medical necessity of an inpatient stay.
Inpatient stay was not medically necessary.
The patient came to the hospital with polyuria in the setting of known diabetes, with noncompliance with medical therapy, and crack cocaine use within 3 days of hospitalization. The patient remained positive for crack cocaine on the urine drug screen; hence she was tachycardic. She exhibited signs of mild dehydration and a mild increase in creatinine. She did not have acute renal failure. Her baseline creatinine was between 0.9-1, and the current creatinine was 1.3. There was no evidence of a severe reduction in glomerular filtration rate (GFR) or documentation of poor urine output or anuria. The renal ultrasound showed no hydronephrosis. There were no severe electrolyte derangements. The patient had mild hypercalcemia, which per documentation, appeared to be a chronic finding. Repeat calcium levels are not found in the medical records. The patient was not exhibiting signs and symptoms of severe hypercalcemia, such as tetanus, lip paresthesias, severe cramping, or cardiac arrhythmias. The electrocardiogram (EKG) was stable.
From a diabetes standpoint, the patient had a known history of diabetes, noncompliant with medical therapy. She has elevated blood glucose values; however, she was not in diabetic ketoacidosis and did not have a diabetic hyperosmolar nonketotic state. The patient was described as alert and oriented x3, and only appeared mildly dehydrated. Mild dehydration, per standard of care treated with IV fluids and reestablishing a diabetes regimen can be performed at a lower level of care.
From a neurologic standpoint, the patient presented with generalized weakness in the setting of prior cerebrovascular accident (CVA). Dehydration, and polysubstance abuse, can cause a reemergence of neurologic symptoms. The patient had a negative head CT scan in the ED. There were no clinical signs of a central nervous system (CNS) infection, seizures, or neuromuscular disorder. There was no report of neurologic trauma. It was reasonable to obtain a brain MRI within 24 hours, to exclude a new stroke definitively; this was not ordered until the day of discharge.
The majority of the work-up was already completed in the emergency department in the initial 8 hours of presentation. Additional care to stabilize blood sugars, reestablish a proper diabetes regimen, and the rest of the work-up could be provider at a lower level than inpatient.