Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal
Treatment: Inpatient Hospital Stay

The insurer denied the Inpatient Hospital Stay.
The determination is overturned in whole.

The patient has a past medical history significant for polymyalgia rheumatica on chronic prednisone therapy, supraventricular tachycardia, and kidney stones who presented to the hospital with complaints of diarrhea. She denied vomiting. The review of systems was positive for generalized abdominal pain as well as some stool incontinence. At the same time, she denied fever, chills, chest pain, shortness of breath, cough, or congestion.
The patient reported recent treatment with the antibiotic Augmentin following a tooth extraction, however, she denied a previous history of Clostridium difficile infection.
Vital signs were a temperature of 97.3 degrees Fahrenheit, pulse 96 beats per minute (bpm), respiratory rate 18 breaths per minute, and blood pressure 96/55.
On the physical exam, the patient was in no apparent distress. She was resting in bed comfortably. The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. The neck was supple without lymphadenopathy, masses, jugular vein distention (JVD), or carotid bruits. The lungs were clear to auscultation without wheezes, rales, or rhonchi. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. The abdomen was soft, tender to palpation, with normal bowel sounds. The rest of the physical exam was unremarkable.
Laboratory evaluation revealed that the white blood cell count was 17.7, hemoglobin 13.3, hematocrit 39.9, and platelets 287. The sodium was 137, potassium 3.9, chloride 104, bicarbonate 15, blood urea nitrogen (BUN) 45, creatinine 2.34, and glucose 176. An electrocardiogram (EKG) revealed sinus rhythm.
A computed tomography (CT) scan of the abdomen and pelvis demonstrated several borderline prominent fluid-filled small bowel loops with fluid that were also noted in the ascending colon. There was minimal scattered colonic diverticulosis. There was a 9-millimeter (mm) partially exophytic structure in the right kidney which was suggestive of a cyst with hemorrhagic debris.
The patient was admitted to the hospital with generalized abdominal pain that was attributed to acute gastroenteritis. Considering that the patient received the antibiotic Augmentin recently, stool studies were sent. Another clinical diagnosis was acute kidney injury that was attributed to diarrhea. This was treated with intravenous fluids.
In the hospital, the patient was seen by a gastroenterologist. The gastroenterologist also suspected that the patient had acute gastroenteritis and recommended a full liquid diet and Protonix.
As a result of the treatment provided in the hospital, the patient's clinical condition significantly improved, including resolution of acute kidney injury that was present on admission and was associated with dehydration due to diarrhea. For polymyalgia rheumatica, the patient continued treatment with prednisone.
During the hospital stay, it was noted that the patient had nonsustained ventricular tachycardia. This was overlaid by the cardiology service. The patient was recommended for continuation of treatment with beta-blockers as well as a 48 hour Holter monitor per the patient's primary care physician (PCP) as an outpatient.
Since the patient's clinical condition significantly improved, she was discharged from the hospital.
At issue is the medical necessity of an inpatient stay.

The admission at the acute inpatient level of care was medically necessary based on the accepted standards of care as the patient was immunosuppressed and presented with a relatively severe infection that led to dehydration and acute kidney failure.
This was an immunosuppressed patient who presented to the hospital with signs of acute gastroenteritis that was associated with dehydration that manifested in hypertension and acute kidney injury. According to the standards of care, patients with acute gastroenteritis require hospitalization if they are immunocompromised.
This is indicated in the Milliman Care Guidelines (MCG) Health Inpatient & Surgical Care 25th Edition criteria for Gastroenteritis.
According to these guidelines, admission at the acute inpatient level of care is indicated for suspected severe infection in the setting of immunosuppression. This patient was on long-term treatment with prednisone due to polymyalgia rheumatica, making this patient immunosuppressed.