Appeal type: Medical necessity
Decision: Overturned

Diagnosis: End Stage Renal Disease (ESRD)

Treatment: Inpatient stay

The insurer denied coverage for inpatient stay.

The denial is overturned.

This patient presented to the emergency department with the history of hypertension in addition to diabetes, multiple sclerosis, coronary artery disease, end-stage renal disease and a prior gastric surgery.  She did have a recent admission for inability to cannulate the fistula and presented again for inability to cannulate her fistula at dialysis earlier that day.  There were multiple attempts made without success.  The physical examination revealed a blood pressure 140/59 with a pulse of 80.  Oxygen saturation was 99% (percent) on room air.  The documentation indicated there was a fistula present to the right arm with many needle marks.  There was a weak palpable thrill with no surrounding tenderness, swelling or erythema.  The documentation indicated she was recommended to undergo a vascular consult in addition to laboratory studies.  She was admitted for further treatment to include repair of the fistula.  The submitted documentation does indicate she did undergo a right upper extremity fistulogram which demonstrated a patent arteriovenous fistula (AVF) with good outflow and no severe flow-limiting stenoses.  She had a balloon angioplasty of venous outflow to aid with cannulation.  She did not have any complication during the procedure.  They attempted dialysis postoperatively; however, the nurses were unable to cannulate.  The physician indicated they mapped out the fistula and the nurses were able to cannulate.  It was recommended she proceed with dialysis as regularly scheduled in follow-up.  The patient was discharged with instructions to follow-up.

This is a patient with end stage renal disease (ESRD) on hemodialysis (HD) for many years, who has been dialyzing 3x (times)/week via a right forearm AVF.  The AVF could not be cannulated and used for dialysis and thus was non-functional.

She presented to the hospital, past regular hours and in the emergency department (ED) she was found to have a very poorly functioning AVF that had very little thrill.  She thus needed a right upper extremity fistulogram and possible endovascular intervention.

It is unclear about the operating room schedule, availability of the surgeons or proceduralists, but the procedure was not able to be performed until the following evening around 2000 hours.  The procedure was complete before midnight and she needed dialysis, and the patient had to stay the night due to the need for the dialysis and lateness of the hour, and thus was discharged the following morning.

It is very common, especially during this pandemic of COVID (coronavirus) 19, that operating room availability for urgent (but not emergent) and elective cases are difficult.  Backup of these processes inevitably results in delays that are unavoidable.  This is especially true in large city ED departments.

There is nothing in the record that indicates that any delay was due to unnecessary testing to other easily correctable factors.  It simply is due to availability of OR (operating room) time and thus the admission and inpatient stay are understandable.

Of course, these types of procedures are nowadays done increasingly at venous access or dialysis access centers with same day procedures and discharges, but since the patient did present to the ED of a large metropolitan/city hospital, delays are very common and should be expected, again in this day and age of the pandemic.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient stay is overturned. Medical Necessity is substantiated.