Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Difficulty Swallowing. 
Treatment: Inpatient Hospital Stay. 

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

The patient has a history of polysubstance abuse and presented to the hospital with difficulty swallowing. The patient developed an oral ulcer causing discomfort for the prior six days. The ulcer was located at the base of the soft palate. He denied any fevers or chills. Twenty-four hours before the presentation, the patient began taking Augmentin and Magic mouthwash, as prescribed by his family doctor. He reported being unable to take any of these medications. The patient appeared emotionally distressed, crying at the bedside about not knowing why he was developing these ulcers. Reportedly, he has had multiple oral lesions in the past. On physical exam, the emergency department record (ED) documents mouth sores that are large erythematous lesions in the mid soft palate descending to the uvula with soft palate edema and erythema. 
Vital signs on arrival include a temperature of 37.3 degrees Celsius (C), a heart rate of 119, and a blood pressure of 116/78. Oxygenation status was stable.
The patient was provided with intravenous (IV) fluids in the ED. He was also given morphine, which improved his pain. On reassessment, the patient's voice was muffled and he still described an inability to tolerate oral food or fluid due to severe pain. 
Laboratory studies revealed a white blood cell count of 1.3 and hemoglobin of 11.5. Human immunodeficiency virus (HIV) testing was offered, but the patient declined. He was admitted to the hospital due to oral intolerance and pain. 
Imaging studies included a chest x-ray which showed no abnormal findings. Ear, nose, and throat (ENT) was consulted, and documented progressive odynophagia and dysphagia. They noted that the patient was seen one year before this presentation for similar oral lesions, was worked up for lymphoma, and underwent a fine needle aspiration (FNA) biopsy of the cervical nodes. The results were negative, but the patient never followed up after the initial assessment. Per ENT, continue supportive care with Magic mouthwash, and they recommended rheumatology follow-up and consideration for infectious disease workup including HIV. The medical team also started the patient on vancomycin and Zosyn for a temperature of 99.1 degrees Fahrenheit.
The next day, ear, nose, and throat (ENT) reassessed the patient and documented ongoing reports of dysphagia and odynophagia. He was tolerating a soft diet. Vital signs appeared stable. On nasal exam, there was a septal perforation. The mouth lesion appeared similar to before. Repeat lab results showed mild hypokalemia. The creatinine was 1.55. The patient was offered a biopsy of the ulcer, but he declined. 
Hematology was also consulted for neutropenia. A review of his medical record notes the bone marrow biopsy performed previously, which showed normal cellularity. In the document, the patient had a fever of 102.6 degrees Fahrenheit. The patient is a smoker but has never used smokeless tobacco. At the time of their visit, the patient was afebrile. A leukemia/lymphoma panel was ordered. Neupogen 300 micrograms (mcg) subcutaneous daily with complete blood count (CBC) monitoring was ordered as well.
Additionally, rheumatology was consulted on this day, assessed the patient, and recommended starting Solu-Medrol 60 milligrams (mg) daily. 
Nephrology was also consulted, for a creatinine of 1.64 on admission, improving to 1.55. A historical review of the patient's renal function showed a creatinine range between 1.4 and 1.8 over the preceding two years. The nephrologist was worried about vasculitis and ordered serology. 
ENT offered a biopsy again, but the patient declined. The vital signs appeared stable. Repeat lab results showed improvement in the creatinine and improvement in the white blood cell count. Education was provided to the patient, regarding the biopsy, as a means of evaluating for oral cancer. 
A repeat computed tomography (CT) scan of the neck without intravenous (IV) contrast showed no focal fluid collection, reactive lymph nodes, bilateral inferior turbinate absence, which could be angiitis or toxic ischemic insult from drugs. The internal medicine team documented the plan to continue with IV Solu-Medrol, Magic mouthwash, and Peridex. The urine drug screen came back positive for cocaine and marijuana. Vancomycin was discontinued after the methicillin-resistant staphylococcus aureus (MRSA) swab came back normal. Zosyn treatment was continued. Procalcitonin was less than 0.5. Hematology offered a bone marrow biopsy exam, and the patient declined. 
The patient was still complaining of pain in the mouth, but there was peeling of the eschar of the mouth ulcer. The medical team attributed the oral mucosal ulcer to levamisole-induced vasculitis. 
Over the next two days, the patient was switched from IV Solu-Medrol to prednisone. By the time of discharge, the leukemia lymphoma panel was still pending, and the patient was instructed to follow up with hematology, ENT on discharge. No antibiotics were prescribed, as all of the blood cultures were negative. 

At issue is the medical necessity of an inpatient stay. 
The inpatient stay for the dates under review was medically necessary. The patient had oral lesions, limiting his ability to maintain adequate hydration and nutrition. He had severe pain, and a description of a muffled voice. He was neutropenic and has failed to improve with outpatient treatment with antibiotics and Magic mouthwash. Based on the provided documentation, the patient's symptoms persisted beyond the observation care assessment. Concurrently, this was causing a mild acute kidney injury (AKI). Rheumatology deemed the ulcer to be levamisole-induced vasculitis, which requires treatment with IV corticosteroids and close monitoring. This condition can lead to multiorgan failure and requires close monitoring. With the concurrent fevers, an infectious process needed to be ruled out. The patient was at risk for airway compromise and complicated deep neck infections. As a result, it was reasonable for the patient to remain in the hospital, with evaluation with a multispecialty approach, stabilization of his condition, and the provision of adequate treatment. The general care could not have been provided at a lower level. Therefore, an inpatient level of care was medically necessary.