Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rhabdomyolysis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient presented to the emergency department with concerns for dark-colored urine and discomfort in several large muscle groups. Initial vital signs revealed a temperature of 36.4 degrees Celsius (C), heart rate (HR) 90, blood pressure (BP) 141/82, respiratory rate (RR) 16, and peripheral capillary oxygen saturation (SpO2) 97% on room air. Initial examination documented minimal tenderness to the bilateral quadriceps and without focal neurological deficits. Initial laboratory testing revealed a white blood cell count (WBC) of 10.5, hemoglobin (Hgb) 14.7, platelets (Plt) 231, sodium (Na) 130, potassium (K) 3.5, blood urea nitrogen (BUN) 9, creatinine (Cr) 0.85, aspartate aminotransferase (AST) 1540, alanine aminotransferase (ALT) 315, total bilirubin (Tbil) 1.0, and a creatine kinase (CK) greater than (>) 100,000. A right upper quadrant (RUQ) ultrasound was unremarkable. The patient was admitted to the hospital with an impression of rhabdomyolysis and transaminitis. The treatment plan included aggressive intravenous fluids at 200 cubic centimeters per hour (cc/hr), daily CK, and monitoring of renal function. There was no significant changes in the physical exam. The urine output was adequate and lab abnormalities improved. Aggressive intravenous fluids were continued. The patient was doing well. Muscle pain improved and the urine was more clear. Intravenous fluids were decreased to 150 cc/hr. CK and transaminases continued to trend downward without signs of acute kidney injury. IV fluids were continued. The CK level decreased below 1000 and the patient was discharged to home.
At issue is the medical necessity of an inpatient stay.
Based on the clinical documentation provided, evidence based literature and standards of care, acute inpatient level of care was medically necessary for the entire admission.
In this particular situation, the patient presented with a markedly elevated creatine kinase of over 100,000 units per liter (U/L) suggestive of significant muscle breakdown. The normal lab range was 20-200 U/L. Despite aggressive intravenous fluids for several days, the CK level remained markedly elevated. Therefore, clinical indications for admission to inpatient care were met. The patient had a need for intravenous hydration well after emergency or observation level care to prevent significant morbidity.[4]
Parekh et al. note rhabdomyolysis is a potentially life-threatening condition caused by a breakdown of skeletal muscle and the release of the intracellular contents into the circulatory system. There are many possible causes, including crush injury, excessive muscular activity, medications, infections, and varied metabolic, connective tissue, rheumatologic, and endocrine disorders. Optimal crystalloid selection is still debated, but immediate, aggressive intravenous volume expansion is indicated to prevent myoglobinuric renal failure. Serum potassium levels must be obtained and electrocardiograms must be evaluated to identify life and limb-threatening complications of hyperkalemia. When recognized and treated early, rhabdomyolysis carries an excellent prognosis. With the exception of hyperkalemia-related death or the rare complication of disseminated intravascular coagulation, acute kidney injury is the most serious complication of rhabdomyolysis, regardless of etiology. Mortality data for patients with renal failure vary widely in the literature according to the study population, etiology, presence of multiple causing agents, and comorbidities; however, long term survival among patients with rhabdomyolysis and acute renal injury tends to be very good when timely management is provided.[1]
Zimmerman et al. note treatment is aimed at discontinuation of further skeletal muscle damage, prevention of acute renal failure, and rapid identification of potentially life-threatening complications. Early and aggressive fluid resuscitation to restore renal perfusion and increase urine flow is agreed on as the main intervention for preventing and treating acute kidney injury (AKI).[2]
Luckoor et al. note in rhabdomyolysis, the CK levels can range anywhere from 10,000 to 200,000 or even higher. The higher the CK levels, the greater will be the renal damage and associated complications.[3]