Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rash to arms and legs.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient has a history of schizophrenia, obesity, and intravenous (IV) drug abuse, and presented to the ER via EMS(Emergency Medical Services) with a tender red rash to his arms and legs which he reported had been present for three weeks. The patient reported associated joint pain in his hands, feet, and legs, along with abdominal pain, a headache, and nocturnal fevers. In the emergency room (ER), the patient had a blood pressure (BP) of 108/68, heart rate of 105 and a temperature of 38.9 degrees Celsius and a respiratory rate of 18, sating 97% on room air. The white blood cell count (WBC) was 9.9 (within normal limits), C-reactive protein (CRP) 24 (elevated), sedimentation rate 105 (high), creatine kinase (CK) 27 (within normal limits), lactic acid 1.3 (within normal limits), alkaline phosphatase (Alk phos) 260 (high), aspartate aminotransferase (AST) 50 (high), alanine aminotransferase (ALT) 85 (high), sodium 133 (low). A chest x-ray was within normal limits. A computed tomography (CT) scan of the abdomen/pelvis showed mild urinary bladder wall thickening, otherwise unremarkable.
On physical exam, the patient had pain on palpation of his left and right lower quadrants along with pain in his joints in his arms and legs along with edema in his feet. The skin had erythematous bilateral nodules on his forearms without ulceration. The patient had not been vaccinated against coronavirus (COVID)-19. The patient was admitted for further work-up. Extensive infectious, dermatologic, and inflammatory work-up was sent which was only remarkable for "labs" consistent with group C strep and the patient was placed on intravenous (IV) penicillin and then transitioned to oral antibiotics (Augmentin). This reviewer could not find the lab results and the finding was stated in the discharge summary. The patient underwent a punch biopsy of his skin lesions by dermatology which showed neutrophil rich panniculitis. The patient was empirically started on oral steroids and topical steroids with improvement during the hospitalization. Patient was discharged with follow-up with dermatology.
At issue is the medical necessity of an inpatient stay.

An inpatient stay was medically necessary. The patient presented with 3 weeks of a rash, pain, nocturnal fevers (documented in the ER to 38.9 degrees Celsius), tachycardia, and headaches. The differential for a presentation includes viral infection, multisystem inflammatory syndrome, autoimmune process, bacterial infection, malignancy, and drug reaction. The presentation in the ER is consistent with a fever of unknown origin with evidence of end organ damage with elevated liver function tests and elevated inflammatory markers. It is necessary to admit the patient in this setting. Mortality rates vary with case series of patients who presented with fever and a rash showing a mortality rate of 5% (Tabak et al 2012). Notably in this case series, the differential diagnoses for the presentation are long and 10 of 100 patients did not receive a definitive diagnosis after a thorough work-up. Labs were not significantly different to help guide whether the presentation was life threatening or not (Tabak et al 2012). Given patient's underlying psychiatric disease along with life threatening medically complicated presentation, it was be reasonable that the patient be admitted to the hospital for greater than (>) 2 midnights to complete an evaluation. Work-up, particularly rheumatologic laboratory work-up, can take >2 days for the assays to be completed given the nature of the testing and need for reflex specific testing. Thus, the inpatient level of care is appropriate for this clinical presentation (complex care plus (+) >2 midnight admission) (Centers for Medicare and Medicaid Services (CMS) guidelines).
This patient could not be appropriately evaluated in the emergency room nor under a lower level of care. The work-up of the presentation is complex and requires admission for >2 midnights (CMS guidelines). Further, the patient has schizophrenia, which is associated with poor medical follow-up, thus it is necessary to complete a thorough evaluation while the patient is admitted to the hospital (Anderson et al 2017). Outpatient work-up is not reasonable in this circumstance. Admission under an inpatient status was appropriate for this patient.