Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis:GU/Kidney disorder
Secondary: Chronic Kidney Failure/ESRD
Treatment: Inpatient hospital stay

This is a patient who presented to the hospital with complaints of nausea. The patient has a history of chronic heart failure, end-stage renal disease on hemodialysis, and experienced the symptoms towards the tail end of dialysis treatment. Symptoms included neck discomfort, difficulty breathing, dizziness, fatigue, and leg swelling. The patient has a known history of coronary disease, with one stent placement, and also has a defibrillator device in place secondary to heart failure. Admitting diagnosis was dyspnea unspecified type with diaphoresis and dizziness. The patient was given a dose of Coreg 25 milligrams (mg) once. Patient reported having severe panic attacks, but denied any chest pains. The patient reported missing hemodialysis treatments due to intermittent diarrhea. Cardiology consultation was requested. Nephrology was also asked to evaluate, for additional dialysis if necessary. The stool was checked for C. difficile, due to reported diarrhea with dialysis. Nephrology, we recommended regularly scheduled dialysis. The cardiology team also evaluated the patient, with an assessment of acute on chronic systolic heart failure secondary to missed hemodialysis treatment. They recommended continuing with hemodialysis to improve volume status. A critical care consult was requested, as the patient became agitated, pulling at telemetry leads, with concern for a possible seizure event. This occurred after hemodialysis, and the patient had a reported tonic-clonic movement. Per evaluation from the critical care team, the patient appeared confused and not responsive. The patient was sent to the intensive care unit and started on Precedex infusion. The patient was started on Depakote, with an escalation of dosing. electroencephalogram (EEG) was started.  The CT scan of the brain was eventually done, video EEG results showed mild to moderate diffuse slowing, more pronounced in the left temporal lobe, no evidence of seizure activity or epileptogenic features. The neurologist felt that empiric treatment with Depakote would be reasonable, despite no evidence of seizure activity. The patient remained intermittently confused, trying to get out of bed, and for her own safety one-to-one sitter was placed at the bedside. The working diagnosis, for the patient's mental status change, includes acute encephalopathy with a seizure-like event, without evidence of true seizures. Psychiatry was asked to evaluate the patient. The psychiatrist felt that the patient is experiencing delirium due to medical condition, and recommended continuing the Klonopin for anxiety and using Abilify for agitation. The health plan's determination is overturned in part. The patient's initial presentation, with a diagnosis of dyspnea, is not warranted at the inpatient level of care. On initial presentation, the patient was hemodynamically stable, had no evidence of pulmonary edema, no hypoxemia, no evidence of decompensated heart failure based on the documentation supplied. Up until the point when the patient developed acute medical delirium, there was no indication for inpatient hospitalization. The patient developed seizure-like activity, with severe encephalopathy, and inpatient hospitalization became necessary. There was a persistent change in mental status that required evaluation with EEG. The patient was so agitated and  required a Precedex infusion in the intensive care unit setting, subsequently followed by an escalation of doses of Depakote, Abilify, and Klonopin. The primary goal in this setting is to rule out medical causes of delirium, which can potentially be life-threatening. This process tends to be slow, and cannot be accomplished under a lower level of care, as a significant amount of resources need to be deployed, to keep the patient safe.  The delirium was preventing the patient from maintaining adequate nutrition and hydration, as well as medical therapy. The medical literature supports admitting the patient to inpatient status, for unknown causes of delirium.