Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Monoclonal Gammopathy of Unknown Origin.
Treatment:  Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is overturned.

This patient with a history of chronic obstructive pulmonary disease (COPD), atrial fibrillation and monoclonal gammopathy.  While in the process of being evaluated for possible amyloidosis, she presented to a clinic complaining of diffuse muscle and joint pain, headache, neck pain, right arm swelling and numbness in her right hand and fingers.  A cardiac magnetic resonance imaging (MRI) scan had suggested infiltrative disease.  She had recently been started on prednisone for possible polymyalgia rheumatica.  In the clinic, her blood pressure was 187/108 millimeters of mercury (mmHg) with a heart rate of 104-108 beats/minute.  Her room air oxygen saturation was 94%.  She became nauseated and vomited once.  On physical, exam right upper extremity weakness and a purpuric rash were noted.  Her white blood cell count was elevated at 19.1.  Her hemoglobin level was 10.4 grams per deciliter (gm/dl).  Her serum troponin level was 0.75 nanograms/milliliter (ng/ml).  An electrocardiogram showed sinus tachycardia without acute ischemic changes.  A computed tomography (CT) scan of the brain and spine showed no acute abnormalities.  The patient was treated with metoprolol and oxycodone and admitted to the hospital.  The medical necessity for an inpatient admission is at issue.

An inpatient level of care was medically necessary.  This patient presented with diffuse myalgias, arthralgias and new neurologic findings.  She met diagnostic criteria for systemic inflammatory response syndrome (SIRS).  SIRS in hospitalized patients is associated with a marked increase in the risk for mortality.  Twenty-eight day mortality in hospitalized patients with SIRS is nearly seven times that seen in patients who do not meet SIRS criteria.  In addition, the patient's serum troponin level was significantly elevated.  Even in the absence of demonstrable myocardial ischemia, troponin elevation in patients with SIRS is a negative prognostic indicator, associated with an increased risk for adverse cardiovascular and all-cause outcomes.  Finally, this patient's brain MRI suggested posterior reversible encephalopathy syndrome (PRES).  In-hospital mortality for patients with PRES ranges from 8-17%; 40% of patients with PRES require intensive care unit (ICU) care.  Complications include seizures and cerebral hemorrhage. 

The patient complained of persistent right arm numbness.  An upper extremity ultrasound showed no evidence of deep vein thrombosis.  Her troponin level increased to 1.58 ng/ml.  Her serum creatinine level increased from 0.8 mg/dl to 1.2 mg/dl.  An echocardiogram suggested an under-filled left ventricle.  A brain MRI scan showed possible posterior reversible encephalopathy syndrome.  The patient continued to complain of right upper extremity numbness, as well as right hand weakness.  Leukocytosis persisted.  Her hemoglobin fell to 9.6 gm/dl.  Her troponin level fell to .73 ng/ml.  A pyrophosphate scan of the heart showed no evidence of cardiac amyloid.  The patient's creatinine level was 1.3 mg/dl.  Electromyography showed the absence of motor activity in the intrinsic muscles of the right hand suggesting a central nervous system etiology.  Her creatinine level was 1.0 mg/dl.  A spine MRI showed diffuse bone marrow heterogeneity.  The patient's symptoms continued over the next several days.  She developed visual and auditory symptoms.  The patient's hemoglobin was 8.9 gm/dl.  A lumbar puncture showed no malignant cells in the cerebrospinal fluid. 

Given this patient's continued symptoms, progressive neurologic complaints and multiple high risk features, an inpatient level of care was medically necessary.