Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Fever, decreased appetite, headache, weakness and abdominal pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned, in part.

The patient is a female with past medical history significant for hepatitis B, non-insulin dependent diabetes mellitus (NIDDM), paraplegia due to motor vehicle accident (MVA), spinal surgery and neurogenic bladder with chronic Foley.  The patient presented with complaints of fever. The patient also reported decreased appetite, headache, fever, weakness and abdominal pain. The patient had received a COVID-19 vaccine one day before. The patient had been on Keflex before presentation to emergency department (ED) (for chronic foot wound). 

The patient's vital signs in the emergency department (ED) showed a temperature of 101.5; hypotension (blood pressure 91/50); and tachycardia at 100-112 beats per minute. The patient was started on intravenous (IV) antibiotics and was admitted for further evaluation and treatment. Plans were made for evaluation by Infectious Disease and Podiatry, Neurology and imaging studies to include computed tomography (CT) of the head and magnetic resonance image (MRI) of foot. The patient was given Tylenol and intravenous (IV) antibiotics Zosyn and Vancomycin. 

On Day 2, the patient continued to have fever and urinalysis was notable for two-plus (2+) ketones.  the patient was continued on intravenous (IV) fluids and intravenous (IV) antibiotics, and cultures awaited. 

On Day 3, the patient's maximum temperature was 99.8 and blood pressure continued to be low (99/49). The patient's urine culture grew Citrobacter.   Intravenous (IV) antibiotics were changed from Zosyn to Meropenem as per input from Infectious Disease consult and urine sensitivity results. 

On Day 4, the patient's fever had improved. Magnetic resonance image (MRI) of the lower extremity showed edema in plantar fascia compatible with plantar fasciitis; early osteomyelitis cannot be excluded. Computed tomography (CT) of the head showed no evidence of acute intracranial pathology.

On Day 5 and Day 6, the patient's fever had resolved and her blood pressure and other vitals had improved and were stable. The patient was continued on Meropenem.  Magnetic resonance image (MRI) was reviewed by Podiatry as low suspicion for osteomyelitis. The patient was tolerating oral feeding already and antibiotics transitioned from Meropenem to oral Levaquin.

Yes, in part; inpatient admission was medically necessary.  However, no, in part; inpatient stay for the last two admission days was not medically necessary.
The patient was admitted with fever, hypotension, tachycardia and varied symptoms concerning for infectious etiology - urinary tract infection (UTI) / post vaccine reaction / question (?) meningitis. The patient was started on intravenous (IV) antibiotics since presentation in the emergency department and was continued on antibiotics during her hospital stay. The patient continued to have fever on day 2, and based on results of the cultures, antibiotic coverage needed to be changed from Zosyn to Meropenem. The patient also underwent evaluation with magnetic resonance image (MRI) of the lower extremity, computed tomography (CT) scan of the head on day 4 and evaluation by consultation - Podiatry and Infectious Disease.   Inpatient stay for the first 4 days was medically appropriate for treatment as above, for work up to exclude other possible etiologies, and for specialist evaluation to decide on need for further treatment if any.  A lower level of care would not have been appropriate for this patient.

However, the last 2 days of admission, the patient was afebrile, with stable vital signs and was tolerating oral feeding without any symptoms to necessitate further work up or investigations. The patient's headache was chronic (since spinal cord surgery) as noted in the records.   Therefore, inpatient stay for the last 2 days was not medically necessary.

Continued inpatient hospital stay is justified and medically necessary when a patient's symptoms, signs, labs and imaging indicate severe illness, high risk of deterioration, unstable comorbid conditions and the need for high intensity, complex and frequent interventions and evaluation. Inpatient care is recommended when a patient's symptoms, signs, imaging data, and labs suggest a moderate to severe illness. Additional factors to take into consideration are the presence of co-morbid conditions, the relative instability of such co-morbid conditions, and the risk of deterioration. The judgement of severity and risk as based on assessment of medical factors in the context of known and generally accepted medical knowledge prevalent. Moderate to high intensity interventions that are required for evaluation and management of the condition also justify an inpatient level of care. Final factors to take into account when judging whether an inpatient admission is medically necessary is the availability of evaluation and management in the alternate setting in an expeditious manner, as mandated by the patient's clinical condition, and appropriate for the patient's medical condition. 

For the last 2 days of admission, the patient was afebrile and had stable vital signs. The patient did not have new symptoms or intractable pain that would require continued management in an inpatient setting. The patient was tolerating oral intake and was clinically stable. Physical exam for this duration did not show any new exam findings that would necessitate further work up in an inpatient setting. Lab results were stable and did not reveal abnormalities that would indicate further need for work up or change in management plan in an inpatient setting. During the above duration, there were no new investigations ordered  / work up initiated, and there was no change in management plans that would justify / necessitate continued inpatient stay in the hospital. During the above duration, the patient's diagnosis had been established clinically based on the results of the investigations. The patient was hemodynamically stable and afebrile. For the above duration, the patient had stable vital signs and routine labs remained at baseline. The patient's temperature and other vital signs were not representative of sepsis during this time. General and systemic examination was normal or at baseline. The patient was able to eat food, drink fluids and take oral medications.  Care rendered during this time was of low intensity, routine nursing and physician monitoring. No systemic findings such as high fever, shock, renal or liver failure or abnormalities of electrolytes or mental status were noted during this time. Examination findings were not concerning and the patient's medical problems did not pose an immediate high risk of deterioration. The patient was not in acute distress and in view of these facts of the patient's  clinical status, the illness was in the post-acute phase and ongoing risk of deterioration was low since diagnosis had been established and patient was responding appropriately to the treatment. The patient had already been switched to Meropenem based on results of cultures and the patient was afebrile and responding to treatment.  The patient did not have any acute complications during this time. No high frequency, high complexity, or high risk procedures or interventions were necessary during this period of time. Since the intensity of interventions was routine, ongoing inpatient care was not medically necessary during this time. With a low severity of illness in the post acute phase and low intensity of interventions during this time, with relative clinical stability, lack of comorbid unstable conditions, and lack of intractable symptoms, ongoing inpatient care was not medically necessary for the above dates. In view of these findings and generally in accordance with Milliman Care Guidelines (MCG) therefore, the ongoing inpatient level of care for the above duration was not medically necessary.