Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Acute Kidney Injury, Dehydration 
Treatment: Inpatient hospital stay 

The insurer is denied coverage for the inpatient hospital stay. The denial is partial overturned.

This is a male patient with a history of kidney cancer with metastasis to the brain and lungs, hypertension, and stroke. The patient presented to the Emergency Department (ED) with complaints of falling after trying to get out of bed. There was no loss of consciousness or head injury. The patient endorsed several days of generalized weakness and an inability to tolerate oral intake. The patient also reported constant, aching right hip, lower back, and left knee pain. The patient's last chemotherapy session was several months prior to this ED arrival. The patient's physical examination was significant for right hip tenderness, left knee ecchymosis, and right paraspinal lumbar spinal tenderness. The patient's x-ray of the left knee revealed no fracture, and the patient's chest x-ray revealed no acute pulmonary process. The patient's creatinine level was 2.21 with a baseline of 1.5. The patient's white blood cell (WBC) count was elevated and sepsis needed to be ruled out. The patient was admitted to the hospital for dehydration, an inability to tolerate oral intake, persistent vomiting, acute kidney injury, and falls of unknown etiology. The plan was to collect blood cultures, collect stool cultures, obtain brain imaging, obtain orthostasis, trend troponin levels, obtain an electrocardiogram, monitor the patient on telemetry, and maintain fall precautions. Hematology and Oncology were consulted. Recommendation were made to continue immunotherapy with Nivolumab. The care plan was implemented and the patient's renal function improved. 

According to McLean & Shaw (2018), "Adverse renal outcomes are associated with significantly increased morbidity, mortality, and cost. Dose and type of [intravenous] fluid administered are implicated in renal outcomes; therefore it is important to use the appropriate fluid. Balanced crystalloids are probably the safest choice for the widest range of resuscitative situations, although albumin solutions can also be used judiciously. Previous methods for estimating fluid requirements are outdated, and have not been proved to improve outcomes; dynamic estimations of fluid requirements are more accurate. It is important to use standard outcome metrics of kidney injury." 

In this case the patient presented with dehydration and acute kidney failure. Due to this
patient's inability to tolerate oral hydration and this patient's persistent fluid loss from vomiting, this patient was at risk for severe dehydration and required intravenous fluid for resuscitation. Studies provide support that intravenous fluids are warranted if the patient's acute kidney failure is caused by dehydration.1,4 However, it appears that discharge planning was initiated after HemOnc recommendations. The note on that day stated that the patient was improving but recommended intravenous (IV) fluids one more day since the patient's kidney function was improving. At that point, transfer to a lower level of care or observation would have been appropriate. Thus, while the initial admission was medically necessary, continued inpatient stay was not medically necessary as this patient's clinical status improved. 

The health plan acted reasonably with sound medical judgment to deny coverage for inpatient stay but did not act in the best interest of the patient to deny coverage. 

The carrier's denial of coverage for the inpatient hospital stay should be partial overturned. Although, the initial inpatient admission stays were medically necessary. The last day of the inpatient stay was not medically necessary.