Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Trauma to the Eye.
Treatment: Inpatient admission.

The insurer denied the inpatient admission.  The denial is upheld.

The patient is a male with medical history significant for Bartter syndrome non-compliant with supplementation, neurofibromatosis type I, short stature treated with growth hormone, and chromosome 16p11.2 microdeletion syndrome, who presented to the emergency department with vomiting and eye trauma. Several hours before presentation he was shot in the left eye with a BB (ball bearing) gun while playing. He did well initially, but after taking a shower had two episodes of vomiting. Because of his medical history, his family was concerned for an electrolyte imbalance because of similar presentation and took him to the emergency department. He vomited a third time en route. He also reported headache. 

The patient's vital signs included temperature 98, heart rate 104, respiratory rate 19, and blood pressure 123/76. His examination was significant for swelling and ecchymosis of the left eyelid with a small abrasion, external ocular movements without pain, focal uptake using fluorescein, no foreign body seen, bruising to the nose (had been fractured the week prior, did not have magnetic resonance image [MRI] as ordered because he lost the prescription), well-appearing, and no significant neurologic findings. 

Electrocardiogram was unremarkable. Laboratory evaluation revealed hypokalemia at 2.5. Renal was consulted with recommendations to check further metabolic studies and administer oral/parenteral potassium replacement. Ophthalmology was consulted. Following complete examination, the patient was given prescriptions for ofloxacin drops, cyclopentolate drops, erythromycin ointment, and Ophthalmology follow-up. The patient's magnesium also returned low. He was treated with parenteral potassium (four doses), enteral potassium (two doses), magnesium, three intravenous (IV) fluid boluses, and Zofran. 

The patient was admitted for electrolyte replenishment and ongoing eye care. Admission orders included potassium every six hours, twice daily magnesium supplementation, ophthalmic treatments as recommended, Tylenol as needed, and regular diet. The patient did well, with resolution of eye pain, blurry vision, and vomiting. The family was offered extensive counselling about the need for medication compliance. He was deemed stable for discharge with prescriptions for potassium, magnesium, and ophthalmic treatments.

No, acute inpatient admission was not medically necessary.

Bartter syndrome is an inherited disorder of renal tubular function characterized by polyuria and associated electrolyte abnormalities (hypokalemia, hypochloremia, metabolic alkalosis, hypercalciuria, and potential hyper-reninemic hyperaldosteronism). There are multiple genetic variants and clinical presentations, many of which present prenatally. Patients often have growth deficits and recurrent episodes of dehydration. Enteral supplementation is essential to electrolyte stability. The majority of patients are also treated with non-steroidal anti-inflammatory medications. 

This male teen with Bartter syndrome and longstanding supplement/medication non-compliance developed vomiting several hours after being hit in the eye with a BB gun. He was taken to the emergency department primarily because of concerns for electrolyte abnormalities, but also to have his eye evaluated. He was admitted for further management of his electrolyte abnormalities. Given, the patient's history of treatment non-compliance, it was reasonable and medically appropriate to attempt electrolyte normalization in the hospital setting. However, the patient was overall hemodynamically stable with no evidence of cardiac dysrhythmia, prolonged vomiting, or severe dehydration. He did not require acute inpatient admission and could have been safely managed at a lower level of care.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.