Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anorexia Nervosa, Weakness.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient had a past medical history of peptic ulcer disease with a recent upper endoscopy 2 weeks prior noting an ulcer, depression, anxiety, hyperlipidemia, anorexia nervosa, and irritable bowel syndrome, who presented to the emergency department with weakness, dizziness, and abdominal pain.
On presentation, she was afebrile with a blood pressure of 95/75, heart rate 51, respiratory rate 18, and oxygen saturation normal on room air. The exam otherwise noted no obvious acute abnormalities. Lab results noted a white blood cell count (WBC) of 4.9, hemoglobin (HGB) 11.7, sodium 132, potassium 3.4, blood urea nitrogen (BUN) 71, creatinine 1.7, acidosis with bicarbonate 13, lipase 118 and liver function tests otherwise within normal limits. The patient was brought into the hospital with a concern for dehydration, acute kidney injury, and possible history of pancreatitis and peptic ulcer disease, and plans for intravenous (IV) fluids, follow up labs, and gastroenterology and psychiatry consultations.
She was seen by gastroenterology with the impression that she had peptic ulcer disease, acute kidney injury, generalized weakness, dehydration, presyncope secondary to dehydration, severe anorexia, and hyponatremia, and with plans for IV fluids, proton pump inhibitor, and checking phosphate, thyroid stimulating hormone (TSH), and gastric and chromogranin levels.
The patient remained hemodynamically stable. Repeat labs were significant for severe hypokalemia to 2.2 in addition to sodium 132, BUN 38, creatinine 1.3, and bicarbonate level 17. She was seen by psychiatry with a note that she had severe anorexia nervosa and with plans to continue Paxil and Zyprexa and have the patient referred to an eating disorders program after she was medically stabilized.
She was seen by nephrology with the assessment that she had hypokalemia, hypomagnesemia, and hypocalcemia and with plans for repletion, in addition to significant non-anion gap metabolic acidosis and with plans for bicarbonate infusion at 100 cc/hr (cubic centimeters/hour).
She remained borderline hypotensive with blood pressures in the 90s. Repeat labs noted hypokalemia to 2.9 with significant hypocalcemia at 6.5 in addition to magnesium of 1.6. The plan was for ongoing electrolyte repletion.
She continued to have systolic blood pressures in the 90s but was otherwise hemodynamically stable. She had ongoing dizziness. Lab results noted a normal potassium Magnesium and phosphorus and calcium were persistently low at 6.7. The plan was to give more IV magnesium and IV potassium and continue sodium bicarbonate tablets as well as Paxil and Zyprexa.
She remained hemodynamically stable. Repeat labs noted a potassium of 3.5 and then 6, with BUN 19, creatinine 1.2, calcium improved to 7.5, phosphorus level low at 2.1, and magnesium 1.9. The plan was to seek placement at an eating disorders program.
She was discharged to an inpatient eating disorders program with close laboratory follow up.
At issue is whether care at the inpatient level of care was medically necessary.
The requested health service/treatment of inpatient stay was medically necessary for this patient.
This is a patient with severe anorexia nervosa who presented with nausea, vomiting, and severe abdominal pain accompanied by severe hypokalemia, hypocalcemia, hypophosphatemia, bradycardia in the 50s, acute kidney injury, and severe acidosis. She required not only initiation of bicarbonate infusion ongoing for multiple days but also multiple doses of electrolyte repletion and frequent labs. She notably was at risk of ongoing bradycardia and hypotension given her refractory hypophosphatemia, hypocalcemia (with calcium as low as 6.5), and hypokalemia (with potassium reaching a nadir of 2.2) and acidosis (with her notably borderline hypotensive throughout her admission), in addition to other fatal ventricular arrhythmias and required several days of IV bicarbonate infusion, aggressive repletion and frequent monitoring of her electrolyte levels, telemetry, and heart rate and blood pressure blood pressure monitoring.  She was appropriate for an inpatient level of care given her presentation and the risk of adverse events.
She had presented with severe acidosis, critical and ongoing hypokalemia as low as 2.2, severe hypocalcemia as low as 6.5, hypophosphatemia and hypomagnesemia requiring IV bicarbonate infusion in addition to numerous repeated episodes of electrolyte replacement at risk for arrhythmias, hypotension, and death was appropriate for inpatient level of care.