Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute kidney injury superimposed on stage 5 chronic kidney disease 
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient with a complex medical history, including anemia, chronic osteomyelitis of the toe of the left foot, stage 5 chronic kidney disease, diabetes mellitus, hypertension, mixed hyperlipidemia, peripheral artery disease, and proliferative diabetic retinopathy of the right eye who presented with complaints of diarrhea, fatigue, and generalized body aches.
A chest x-ray showed no active cardiopulmonary disease, and a computed tomography (CT) scan of the head revealed no acute intracranial abnormalities.
The patient was admitted to the hospital with hypertensive urgency, attributed to poor medication compliance and acute kidney injury superimposed on stage 5 chronic kidney disease (CKD). Another clinical diagnosis made was type I diabetes mellitus.
During his hospital stay, the patient was evaluated by a nephrologist who confirmed the diagnosis of acute kidney injury superimposed on chronic kidney disease due to dehydration.The patient's blood pressure was brought under better control, and an electrocardiogram (EKG) showed normal results. The importance of medication compliance was emphasized during the hospitalization.
At issue is the medical necessity of an inpatient level of care.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care. Based on the patient's symptoms which included fatigue, generalized body aches, and diarrhea, there was a high probability that the patient had acute viral gastroenteritis.
Based on the nationally accepted standards of care, admission at the acute inpatient level of care in cases of gastroenteritis is usually justified when patients present with a severe infection that manifests as bloody diarrhea, or in cases when patients are immunosuppressed. Another indication for acute inpatient level of care is severe abdominal pain or the presence of peritoneal signs on exam. Admission at the acute inpatient level of care is also indicated for patients with toxic megacolon, hemodynamic instability, severe or persistent dehydration, or severe electrolyte and metabolic abnormalities that persist despite observation care. Other indications for acute inpatient level of care include hemolytic uremic syndrome or inability to maintain oral hydration after the emergency department and observation care treatment.
Based on the information available, the patient had none of the symptoms listed above. At the time of admission, the patient's blood pressure was severely elevated, however, by the time the patient was seen by the admitting physician the blood pressure was controlled much better and close to the normal range. This patient had hypertensive urgency, a condition that generally does not require admission at the acute inpatient level of care. There is no evidence that the patient in fact had acute kidney injury that was persistent despite observation care. He was likely slightly dehydrated, and that caused some elevation of his creatinine levels.

Overall, the patient's hospital stay was very short and could have been handled at a lower level of care. This patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.