Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infectious Disease - Bandemia
Treatment: Inpatient Hospital Admission
The insurer denied Inpatient Hospital Admission.
The denial is upheld in whole.

The patient is a female with a past medical history significant for hypertension, prediabetes, and hyperlipidemia who came to the emergency department with complaints of generalized skin rash for two weeks. She was initially evaluated in the urgent care and was prescribed prednisone which she took for a few days; however, it did not help much, and she came to the emergency room (ER).
In the emergency department, the patient received treatment with corticosteroids with improvement in her symptoms, and she was discharged home from the ER since she did not want to remain in the hospital. Following that hospital visit, her symptoms which included skin rash or pruritis, resolved. The patient was called back to the hospital due to the finding of bandemia in her lab work. At that time the patient had no complaints. 
In the emergency department, the patient was found to be tachycardic and received treatment with intravenous antibiotics including Vancomycin and Zosyn. It was also noted that the patient's troponin was elevated, therefore she was admitted for further evaluation and management. On physical exam, the patient's temperature was 98.3 F (degrees Fahrenheit), blood pressure was 121/76, respiratory rate was 20 breaths/minute, and oxygen saturation was 99% on room air.
Laboratory evaluation revealed that white blood cell count was 5.09, hemoglobin was 10.7, hematocrit was 33.3, and platelets were 182. Sodium was 141, potassium was 3.9, chloride was 108, bicarbonate was 25, blood urea nitrogen (BUN) was 14, creatinine was 0.61, glucose was 133, and troponin was 281.
The patient was admitted to the hospital with several medical problems including elevated troponin and a skin rash associated with bandemia.
In the hospital, the patient was seen by a cardiologist. The cardiologist stated that the patient's troponin was elevated; however, she was asymptomatic. Therefore, the cardiologist suspected that the patient's elevation of the troponin levels could be related to demand ischemia. 
During the hospital stay, the patient was seen by an infectious disease specialist who stated that the bandemia was improving. The infectious disease specialist recommended blood cultures as well as rechecking her complete blood count (CBC).
At issue is the medical necessity of the Inpatient Hospital Admission.

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

The requested health service/treatment of Inpatient Hospital Admission was not medically necessary for this patient.
Overall, this patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the inpatient level of care. The patient was called back to the hospital due to the presence of bandemia in the laboratory results. However, she was afebrile and hemodynamically stable. The mild tachycardia that the patient had at the time of admission improved within the first couple of days of the hospitalization. In addition, the patient was completely asymptomatic and did not report nausea, vomiting, or diarrhea. The patient was able to tolerate oral intake. Considering the fact that the suspicion for infection was very low, there was no need for the administration of intravenous antibiotics. Even though the patient had elevated troponin levels, there was no strong clinical evidence of acute coronary syndrome, and the patient did not need any intervention for this. The skin rash that the patient had before this admission became significantly better even before the day of the presentation.
Therefore, the requested health service/treatment of Inpatient Hospital Admission was not medically necessary.