Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infectious Disease-Other/Sepsis
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

This case involves a patient with a history of coronary disease, a history of ST-Elevation Myocardial Infarction (STEMI), who was called into the emergency department because blood cultures were drawn three days before grew out gram-negative rods. The patient was reportedly admitted for a STEMI and underwent stenting to his left circumflex artery. The patient developed a fever of 101.8, which prompted blood cultures in the hospital, but subsequent temperatures were normal. There was no growth on the bacterial culture for 48 hours; therefore, he was released from the hospital without antibiotics. Repeat blood cultures were ordered in the emergency department (ED), and a chest x-ray. The white blood cell count was 7.4, with hemoglobin of 11.2. The electrolytes, renal function, and liver function test are normal.
The principal admitting diagnosis is gram-negative rod bacteremia. The medical team started the patient on Zosyn and continued his cardiac regimen. The medical attending documents no signs of systemic inflammatory response syndrome (SIRS) or sepsis at admission. The patient remained in the hospital for 48 hours, receiving intravenous (IV) Zosyn. The speciation on the blood culture showed Corynebacterium species. The repeat cultures remain negative. As a result, the patient was medically cleared and discharged home without antibiotic therapy.

The requested health service for inpatient stay is not medically necessary for this patient.
The patient was called back to the hospital due to concerns for gram-negative bacteremia. The patient is afebrile, without signs of Sirs or sepsis on arrival. The blood cultures were obtained several days before, and per the documentation, were gram-negative bacteria per the Gram stain. However, the actual bacterial culture grew out Corynebacterium species, typically gram-positive organisms, and is usually associated with blood culture contamination from skin puncture. During the time spent in the hospital, the patient remained afebrile, hemodynamically stable, without overt clinical illness. The repeat cultures remain negative. As a result, the logical conclusion is that the initial blood culture sample was contaminated and not representative of true gram-negative bacteremia.
The patient has no clinical signs of gram-negative bacteremia or sepsis. The blood culture likely represented contamination and not a true infection. Clinical gram-negative bacteremia is a severe illness requiring aggressive IV antibiotics and close monitoring. However, in this case, severe illness is not noted. The patient has a normal white blood cell count, no obvious source of infection, and no recurrent fevers. Repeat blood cultures, despite no antibiotics for three days, remain negative. This is contamination, i.e., false positive, based on clinical literature. Therefore, inpatient stay is not medically indicated. However, it was reasonable to admit the patient for lower level of care to delineate true infection versus contamination.