Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Other- Muscle breakdown 
Treatment: Inpatient emergency admission

The health plan denied: Inpatient emergency admission 
The determination is: Overturned

The patient is a male who presented with left upper extremity swelling for one day. He reported just starting lifting weights and lifted weights for several hours a few days ago. He then noticed left arm swelling the following day and pain similar to post exercise soreness. He was seen at urgent care and then referred to the emergency room for further workup. He denied chest pain, nausea, shortness of breath or vomiting.
His vital signs showed that he was afebrile with a heart rate of 104 beats per minute (bpm), a blood pressure of 182/122  millimeters of mercury (mmHg), a respiratory rate of 18 breaths per minute and a room air pulse oximetry of 98 percent (%). On exam, he had diffuse left arm swelling, soft compartments, no tenderness to palpation, and full sensation and range of motion. His labs showed a creatine kinase (CK) level greater than 42,670, an aspartate aminotransferase (AST) of 1658, an alanine aminotransferase (ALT) of 329, a creatinine of 1.01, a potassium of 3.8, and a carbon dioxide (CO2) of 23.5. A left arm ultrasound showed a possible hematoma, but no deep vein thrombosis (DVT) was visualized. A left upper extremity computed tomography (CT) scan showed edematous changes in the biceps region. His urinalysis was positive for blood, but his red blood cell (RBC) count was within normal range. He was admitted to inpatient medicine for further evaluation and treatment of rhabdomyolysis. He was started on aggressive fluid resuscitation. Surgery was consulted and no surgical intervention was indicated at that time. Nephrology was consulted and recommended increasing the fluid rate to 300 milliliters per hour (cc/hr) . His CK level remained elevated greater than 42,670. It was further quantified and peaked at 101,858 with a trend toward improvement down to 64,000. Gastroenterology was consulted for transaminitis, which was thought to be secondary to rhabdomyolysis and recommended to continue current therapy. His liver function tests did also slowly improve with treatment. The patient noted continued improvement in left arm swelling. He was discharged home with follow up with his primary care physician (PCP) with additional lab testing to repeat CK and liver function testing.
At issue is the medical necessity of the inpatient hospital stay.
The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of inpatient hospital stay was medically necessary for this patient based on the documentation provided. The patient presented with a major muscle injury after weightlifting several days prior. He had severe swelling with a CK level greater than 100,000 and significant elevations of AST and ALT levels. He was at high risk for complications such as acute kidney injury, compartment syndrome, and limb ischemia. He required inpatient management with aggressive hydration and close monitoring that could not have been safely provided at an alternative level of care. An inpatient level of service was reasonable and medically necessary in this case.