Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Decreased kidney function.
Treatment: Inpatient hospital admission.
The insurer denied: Inpatient hospital admission.
The denial is: Upheld.

The patient is a male with a past medical history significant for coronary artery disease, coronary artery bypass graft (CABG), transient ischemic attack (TIA), insulin-dependent diabetes mellitus, hyperlipidemia, and hepatitis C virus (HCV) who presented to the hospital with dyspnea on exertion for several months. The patient came to the hospital with similar complaints just a week before the current presentation. At that time, he was diagnosed with renal dysfunction but decided to leave the hospital against medical advice. He came to the hospital requesting a reevaluation of his kidneys as well as dyspnea.

The review of systems was positive for shortness of breath, chest pain, abdominal pain, flank pain, and back pain. The rest of the review of systems was negative.
At the time of the initial evaluation, the patient was afebrile. His blood pressure was 121/78, pulse rate 61 beats per minute (bpm), respiratory rate 18 breaths/minute, and oxygen saturation 96% on room air.
The head, eyes, ears, nose, and throat (HEENT) exam was within normal limits. The patient had a regular rate and rhythm, without murmurs, rubs, or gallops. Lungs were clear to auscultation without wheezes, rales, or rhonchi. There was left costovertebral angle (CVA) tenderness but no guarding or rebound. The rest of the physical exam was unremarkable.
Laboratory evaluation revealed that white blood cell count was 9.6, hemoglobin 11.7, hematocrit 35.9, and platelets 109. Sodium was 139, potassium 5.5, chloride 106, bicarbonate 24, blood urea nitrogen (BUN) 50, and creatinine 2.57. Urinalysis was unremarkable.
During the hospital stay the patient underwent computed tomography (CT) scan of the abdomen and pelvis without intravenous contrast, which demonstrated descending gallbladder and cholelithiasis, but no evidence of hydronephrosis.
The patient also underwent abdominal ultrasound, which revealed a distended gallbladder with sludge and punctate stones. There was no gallbladder wall thickening or pericholecystic fluid. There was a negative sonographic Murphy sign. There was no biliary ductal dilatation.
His treating provider stated that during the hospital stay it was planned for the patient to undergo an echocardiogram and consult with gastrointestinal (GI) service, but this was not done since the patient left the hospital against medical advice (AMA).

The health plan's determination is upheld.

The inpatient hospital admission was not medically necessary for this patient. Per the Kidney Disease Improving Global Outcomes (KDIGO) Clinical Practice Guideline for Acute Kidney Injury (1), acute kidney injury (AKI) is defined as any of the following:
- Increase in the serum creatinine value of greater than or equal to (>=) 0.3 milligrams per deciliter (mg/dL) (26.52 micromoles/Liter) in 48 hours,
- Increase in serum creatinine of >= 1.5 times baseline within the prior 7 days,
- Urine volume less than (<) 0.5 milliliter (mL)/kilogram (k)g/hour for 6 hours.
In this particular case, the patient had a creatinine of 2.57. The patient's creatinine was 1.99. Therefore, by definition, there was no increase in serum creatinine of >= 1.5 times baseline within the prior 7 days. Furthermore, there was no information that the patient's creatinine rose >= 0.3 mg/dL (26.52 micromoles/Liter) in 48 hours, or the urine volume < 0.5 mL/kg/hour for 6 hours.
Secondly, the treatment provided within the first several hours effectively decreased serum creatinine level down to 1.67, with complete resolution of hyperkalemia.
Furthermore, a computed tomography (CT) scan of the abdomen and pelvis did not reveal evidence of hydronephrosis.
In addition, throughout the entire hospital stay the patient remained afebrile and hemodynamically stable.
Even though the patient complained of some shortness of breath, there were no signs of acute respiratory failure. The patient had a normal respiratory rate and normal oxygen saturation.
The minimal elevation of troponin was likely related to an abnormality in kidney function and not related to acute coronary syndrome.
The patient's thrombocytopenia was related to a previous diagnosis of hepatitis C virus infection. It was not associated with any bleeding.
The patient could have been managed at a lower level of care status.