Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute kidney injury

Treatment: Inpatient admission

The insurer denied coverage for an inpatient admission

The denial is overturned.

The patient is a female who presented to the emergency department via ambulance for three days of bilateral flank/back pain radiating to both hips and posterior legs. She reported difficulty ambulating. Her medical history included hypertension, dyslipidemia, chronic kidney disease, congestive heart failure (CHF) and osteoarthritis. She had no red flag symptoms. She reports marked and worsening weakness over the past few weeks and a dry cough. No chest pain or shortness of breath. Vital signs within normal limits. Lab values note an H&H (hemoglobin and hematocrit) of 7.4/26.9. BUN (blood urea nitrogen) /Creatinine 31/2.65. She was given intramuscular NSAID (non-steroidal anti-inflammatory drug) and oral muscle relaxant. The emergency department (ED) course states positive for Covid-19. Her work up is remarkable for anemia, most likely secondary to her chronic kidney disease (CKD). She also has an acute kidney injury on top of her chronic renal insufficiency. No acidosis although CO2 (carbon dioxide) is mildly decreased. Her exam is normal. The plan was to continue intravenous (IV) fluids. Chest x-ray unremarkable, computed tomography (CT) abdominopelvic is unremarkable. No suspicion for urinary infection. In the setting of poor oral intake, she was admitted for IV fluids, continuation of care and further evaluation and management. Internal Medicine notes inpatient needs due to acute kidney injury and covid-19, patient at risk for progression of disease and death.

The patient had an onset of severe pain not relieved with IV Toradol, dexamethasone, morphine and oral Flexeril. Her pain was sustained at a high rate ranging from 6 to 10/10 (on a pain scale of 1-10), not effectively relieved with oral medications, and IV Dilaudid was added. She required oral Percocet and IV Dilaudid until she underwent an epidural steroid injection which relieved her pain. PT (physical therapy) recommended ongoing treatment for generalized weakness. CT and MRI (magnetic resonance imaging) showed mass effect on her bilateral L (lumbar) 5 nerve roots due to a significant spondylolisthesis. The inpatient stay was medically necessary per MCG (Milliman Care Guidelines) Low Back guideline, extended care is needed for medication and possible surgical intervention.

MCG Back Pain 
Inpatient:

1)	Severe pain requiring acute inpatient management
2)	Extended Stay
3)	Disk disease, spondylosis, or spinal stenosis as etiology of severe pain or functional     deficit (without myelopathy)
4)	Anticipate therapy, medication, and possible surgical intervention.
5)	Expect brief to moderate stay extension (1).

In addition, patients with higher scores on the Modified HEDIS (healthcare effectiveness data and information set) criteria and with severe back pain rated 10/10 were found to be at sequentially higher risk. Patients with higher risk scores are more likely to require extended hospital stays as well as substantially higher rates of intervention and should therefore be considered for hospital admission rather than observation. (2)

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for an inpatient is overturned. Medical Necessity is substantiated.