Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Infectious Disease - Bacterial infection.
Treatment: Inpatient Hospital.
The insurer denied Inpatient Admission.
The denial is overturned. 

The patient was a generally healthy male who presented to the hospital with a history of nausea, vomiting, and diarrhea. The patient reported that he recently went to Mexico for a wisdom tooth extraction. Before the surgery, he took a 2-day course of Amoxicillin. After the surgery, he took Clindamycin for 3 days. He returned to the United States in his usual state of health. Subsequently, he developed fatigue and nausea. Following that, he developed profuse watery diarrhea with one episode of melanotic stool. After this episode, he had not had any melanotic stools. On the next day, he developed right lower quadrant abdominal pain and went to see his primary care physician. Subsequently, he developed vomiting.

The patient also reported scrotal pressure but denied any blood in the urine. The patient reported no sick contacts. He did not drink any non-bottled water in Mexico. The abdomen was soft, non-tender to palpation, with hyper-pitched bowel sounds, without guarding or rebound. The rest of the physical exam was unremarkable.
Laboratory evaluation revealed that white blood cell count was 10.73, hemoglobin was 14.6, and platelets were 346. Sodium was 140, potassium was 4.0, chloride was 105, bicarbonate was 27, and creatinine was 2.4. Liver function tests were unremarkable.

Gastrointestinal (GI) polymerase chain reaction (PCR) was positive for Shigella, norovirus, Enteropathogenic Escherichia coli (EPEC), and Enteroaggregative Escherichia coli (EAEC). The computed tomography (CT) scan of the abdomen and pelvis revealed no renal stone or hydronephrosis. It was reported as an unremarkable study.

The patient was admitted to the hospital with acute gastroenteritis. He was started on Ciprofloxacin and was encouraged oral intake. He was treated with intravenous fluids due to acute kidney injury. It was mentioned that the melanotic stools resolved. In the hospital, the patient was seen by an infectious disease specialist who suggested the continuation of treatment with Ciprofloxacin. In the hospital, the patient underwent a testicular ultrasound that demonstrated no acute pathology. As a result of the treatment, the patient's clinical condition improved. The serum creatinine started to trend down, going down to 1.8.

Since the patient's clinical condition continued to improve, he was discharged home with a recommendation to follow up with a primary care physician.
At issue is the medical necessity of Inpatient Admission.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of Inpatient Admission was medically necessary for this patient.

Based on the clinical documentation, this patient had severe acute gastroenteritis caused by bacterial/viral infection, which required treatment with antibiotics. Most importantly, this patient required the administration of intravenous fluids for acute kidney injury that was caused by severe dehydration due to decreased oral intake in the setting of persistent nausea and vomiting. In addition, based on the clinical documentation, the patient's serum creatinine was 2.4 at the time of admission. Even though the patient received treatment with intravenous fluids, his kidney function improved only modestly. It was indicated that the serum creatinine went down to 1.8, which was still significantly above the normal range, especially for an individual with previously normal kidney function. The admission at the acute inpatient level of care was justified to ensure the resolution of gastrointestinal symptoms, monitor oral intake, and administer intravenous fluids (IVF).
Therefore, the requested health service/treatment of Inpatient Admission was medically necessary for this patient.