Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath. 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is upheld. 

The patient is an adult male who was admitted for worsening shortness of breath. He has history of end stage renal disease and was evaluated by nephrology and underwent dialysis treatment for ultrafiltration and volume removal, which he tolerated well and breathing was improving. He had history of dialysis catheter infection; intravenous (IV) antibiotic regimen was continued. The patient's volume status was improved, and the patient was discharged in stable condition on day #4. 

The proposed treatment was not medically necessary. 

Per Milliman Care Guidelines (MCG): M-326 criteria, admission is indicated for one or more of the following: * Acute[B] renal failure (stage III acute kidney injury), [A] as indicated by one or more of the following: 
 1) three-fold rise in serum creatinine from baseline [NOT MET; there was no documented baseline.] 
 2) Serum creatinine greater than four milligrams per deciliter (mg/dL) (354 micromoles per liter) with acute rise greater than 0.5 milligrams per deciliter (mg/dL) (44.2 micromoles per liter) 
[NOT MET; the patient's creatinine was less than four milligrams per deciliter.] 
 3) Reduction of more than 75% in estimated glomerular filtration rate from baseline [NOT MET; there was no documented baseline.] 
 4) Anuria [NOT MET; anuria was not documented.] 
* Acute[B] kidney injury[A] (e.g., rise in serum creatinine, reduction in estimated glomerular filtration rate from baseline) requiring inpatient care, as indicated by one or more of the following: 
 1) Hemodynamic instability [NOT MET; this is not documented.] 
 2) Cardiac arrhythmias of immediate concern [NOT MET; this is not documented.] 
 3) Worsening clinical status (e.g., rising creatinine) despite observation care (e.g., hydration) [NOT MET; this is not documented.] 
 4) Altered mental status [NOT MET; this is not documented.] 
 5) Severe hypertension (systolic blood pressure [SBP] greater than 180 millimeters of mercury (mmHg) or diastolic blood pressure [DBP] greater than 120 millimeters pr mercury (mmHg) in adults or greater than the 95th percentile for age, gender, and height in pediatric patients) [NOT MET; this is not documented.] 
 6) Hypoxemia (e.g., due to pulmonary edema) [NOT MET; this is not documented.] 
 7) Electrolyte abnormality that is severe (e.g., hyperkalemia with severe electrocardiogram [ECG] findings) [D] or persists despite observation care [NOT MET; this is not documented.] 
 8) Metabolic abnormality (e.g., acidosis) that is severe or persists despite observation care [NOT MET; this is not documented.] 
 9) Dialysis needed (e.g., new to dialysis, no established vascular access) [NOT MET; this is not documented.] 
 10) Suspected etiology needing inpatient care (e.g., Goodpasture syndrome, vasculitis, possible need for plasmapheresis) [NOT MET; this is not documented.] 
 11) Other finding or manifestation of acute renal disease necessitating inpatient care (e.g., hemoptysis, Anasarca) [NOT MET; this is not documented.] 

This patient was hemodynamically stable, with normal oxygenation and negative cultures, and did not have significant electrolytes disturbance or change in kidney function. The patient did not have cardiac arrhythmias, no altered mental status or persistent nausea and vomiting with dehydration. There was no documentation of refractory pain, and he was able to tolerate oral diet and did not require total parenteral nutrition. 

Based on the patient's presenting signs/symptoms and the predictability of something adverse occurring to the patient based on these presenting signs/symptoms, the patient's condition could have been treated safely under a lower level of care. When taking into account the patient's exam, imaging, and lab findings as well as his lack of need for diagnostic testing beyond what was done under observation care and the availability of any additional diagnostic testing as an outpatient, nothing was done for the patient during his inpatient level of care that could not have been or had not already been managed on an observation level of care. Based on all these reasons, the patient had no requirements for inpatient level of care.