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 has a past medical history significant for hypothyroidism, hypertension, and type II diabetes mellitus who presented to the emergency department after she had a sudden episode of shortness of breath, diaphoresis, and lightheadedness that began on the day of admission.

Reportedly, Emergency Medical Services (EMS) was called, but the patient refused to go to the hospital since her symptoms significantly improved. However, upon returning home she began to experience bilateral hand cramping/stiffness. She felt short of breath and diaphoretic. This prompted her to come to the emergency department.

At the time of the initial evaluation, the patient was afebrile. Her heart rate was 73 beats per minute (bpm), respiratory rate 24 breaths/minute, blood pressure 104/64, and oxygen saturation 96% (percent) on room air.

The patient was in no acute distress. The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. The lungs were clear to auscultation without wheezes, rales, or rhonchi. The abdomen was soft, non-tender to palpation, with normal bowel sounds, without guarding or rebound. The rest of the physical exam was unremarkable. Laboratory evaluation revealed that serum sodium was 139, potassium 4.3, chloride 105, bicarbonate 24.1, blood urea nitrogen (BUN) 31, creatinine 1.64, glucose 175. Lactate was 2.99. White blood cell count was 17.3, hemoglobin 13.6, hematocrit 43.7, platelets 212. The urinalysis was unremarkable.

An electrocardiogram (EKG) demonstrated normal sinus rhythm with left anterior fascicular block and nonspecific ST-T (EKG interval) changes.

The chest x-ray did not show acute abnormalities. A computed tomography (CT) scan of the chest revealed an enlarged thyroid on the right side with a calcified left thyroid nodule. It also showed mild cardiomegaly and multiple splenic aneurysms.

Because of the acute kidney injury, the patient underwent a renal ultrasound that showed no hydronephrosis. The patient also underwent a lower extremity venous duplex that was negative for a deep vein thrombosis (DVT).

The patient was admitted to the hospital with a diagnosis of acute kidney injury. The treatment with Losartan/hydrochlorothiazide (HCTZ) was placed on hold. Metformin was also held. She received treatment with intravenous fluids.

Repeat laboratory evaluation demonstrated resolution of the acute kidney injury. The patient's creatinine came down to 1.25. Since the patient's clinical condition significantly improved, she was discharged home.

At issue is the medical necessity of an inpatient stay.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.

A review of the medical records demonstrated that the patient's symptoms, physical exam, results of diagnostic studies, and laboratory tests did not point to the presence of acute medical problems that required admission at the acute inpatient level of care. This patient was mildly dehydrated, which resulted in mild acute kidney injury that resolved within a very short period of time.

The dehydration was possibly related to the use of diuretics and angiotensin II receptor blockers (ARB), which were discontinued. The use of Metformin could lead to lactic acidosis, especially in the setting of mild kidney injury.

All of these problems significantly improved within hours of the hospitalization, allowing the patient to be discharged on the day of admission.

Taking into consideration this information, workup was necessary to ensure the resolution of kidney injury and lactic acidosis. However, neither the severity of the patient's condition nor the complexity of the services provided rose to the acute inpatient level of care.

There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care. 

Overall, 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.