Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Nephrotic syndrome and acute kidney injury

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is overturned.

The patient was admitted at the hospital on the Pediatric Nephrology service for the management of his nephrotic syndrome and acute kidney injury with possible requirement of dialysis. Prior to that admission, he was seen in the pediatric nephrology clinic for a second opinion. He had been started on dialysis when he was admitted to a hospital where he didn't respond to medical management of his fluid overload and needed dialysis to alleviate uremic symptoms. After his discharge, he continued outpatient dialysis sessions there. His family sought a second opinion and care was transitioned to another hospital for continued outpatient hemodialysis three times a week. At the time of the first clinic visit, the patient had not undergone a diagnostic biopsy to explain the cause of his unusual presentation, namely nephrotic syndrome with significant acute kidney injury needing dialysis. He was also not receiving any specific therapy (i.e. [that is], immunosuppression) to treat his underlying disease at that time. The plan was to perform a diagnostic biopsy. The doctor recommended inpatient admission prior to performing the biopsy, given that the patient was on dialysis, and she made a preliminary plan on how to alter the dialysis treatment to allow for a safe biopsy (administering citrate instead of heparin given during the session to minimize the risk of bleeding). 

The admission is justified, as a patient undergoing a percutaneous renal biopsy is at risk of bleeding. The risk is significantly increased when a patient requires hemodialysis during which they receive anticoagulation to prevent clotting during the procedure. At the time the biopsy was planned, the patient remained on intermittent dialysis and the fact that he wouldn't need it on the day prior to the biopsy was unknown as renal function recovery is difficult to predict. The team wanted to time the dialysis with the biopsy in such a way that the risk of bleeding could be minimized. This is difficult to do when a patient is being dialyzed at an outside institution. Transferring a patient's dialysis care from one institution to another would have delayed the diagnostic biopsy significantly and thus inpatient hospital admission with dialysis was the most efficient way to allow for the team to start specific treatment for the condition. Based on the biopsy findings, the patient was also started on treatment while admitted and he could be closely monitored for side effects of the treatment, including hypertension, for which he was started on antihypertensive medication. The inpatient hospital admission is considered medically necessary for this patient.

Aaltonen, S., et al reports a bleeding risk of 11% (percent) in patients without additional risk factors of bleeding. "Having nephrotic syndrome (with secondary dyslipidemia) and being on dialysis both amplify the risk manifold." [1]

The insurer's denial of coverage for inpatient admission is overturned. Medical necessity is substantiated.