Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Skin Rash.
Treatment:  Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

The patient presented to the emergency department with complaints of fever and skin rash.  Reportedly, the patient was recently evaluated by a rheumatologist.  At the time, she was started on sulfasalazine with improvement in her joint symptoms.  The patient had been seen by her primary care physician for upper respiratory tract symptoms.  She was prescribed treatment with Tamiflu for a few days.  She developed a skin rash initially on her feet, but subsequently it progressed to the entire lower extremities.  In the next several days, the pruritic rash continued to progress to the face and entire body.  At that time, the patient started to experience intermittent fevers.

Reportedly, the patient called her rheumatologist and was prescribed a Medrol Dosepak. Despite taking the medication, she had little response.  At that time, the patient also stopped taking sulfasalazine, Omeprazole, and Ibuprofen.  The patient went to several urgent care clinics where she received a prescription for Zyrtec, Singulair, Prednisone.  On the date of admission, the patient went to a clinic where she was found to have a temperature of 101.7 degrees Fahrenheit, and a heart rate of 111 beats per minute (bpm).  Therefore, she was directly admitted to the hospital.

When the patient was seen by the admitting physician, her temperature was 99.5 degrees Fahrenheit (F), blood pressure 107/74, respiratory rate 18, and heart rate 115 beats per minute (bpm).  The patient was in no acute distress, and was alert, and oriented.  She had an essentially normal head, eyes, ears, neck, throat (HEENT) exam.  The neck was supple without lymphadenopathy or thyromegaly.  The lungs were clear to auscultation without wheezes, rales, or rhonchi.  The patient had a regular heart rate and rhythm without murmurs, rubs, or gallops.  The abdomen was soft with positive bowel sounds, no hepatosplenomegaly.  The skin exam revealed diffuse erythematous maculopapular rash on the legs, arms, chest, back, and face.

Laboratory evaluation revealed that the white blood cell count was 11.4, hemoglobin 11.9, and platelets 386.  The sodium was 132, potassium 4.4, chloride 96, bicarbonate 20, blood urea nitrogen (BUN) 17, creatinine 1.35, and glucose 102.  The liver function tests were normal.

The patient was admitted to the hospital with a skin rash and fever.  The admitting physician suggested that the patient could have a hypersensitivity reaction to one of her medications.  Presumably, it was sulfasalazine.  Another clinical diagnosis was acute kidney injury, which was possibly related to poor oral intake and fever.

During the hospital stay, the patient was seen by a dermatologist, who suggested that the patient could have a hypersensitivity reaction to medications versus drug-induced systemic lupus erythematosus (SLE) versus serum sickness.  The dermatologist recommended additional lab work, as well as treatment with antihistamine medications and some topical treatments.  The patient was also seen by a gynecologist, who evaluated the patient for vulvar urethral pruritus and burning in settings of urination.  On the pelvic exam, the patient had two small abrasions at the introitus and near the urethra, which was the most likely cause of symptoms.  There was no abnormal discharge and no vaginal bleeding.  The gynecologist stated that no treatment was necessary at the time.

During the hospital stay, the skin rash and intermittent fevers improved with topical steroids.

The anti-nuclear antibody (ANA) test was positive, came at 1:640 titer, in combination with elevated histone antibodies was suggestive of drug-induced lupus.

The patient was recommended to continue cold compresses for the fever and occasional ibuprofen as needed, along with topical treatment with Hydrocortisone cream and TAC ointment twice a day, and to avoid sulfa drugs.

The patient's kidney function did not improve after the administration of intravenous fluids; therefore, she was advised to monitor kidney function as an outpatient and avoid nephrotoxic agents.

The patient was suspected to have a urinary tract infection and received one dose of ceftriaxone with a recommendation to follow up on the urine culture results, which was obtained prior to the administration of antibiotics.  At issue is the medical necessity of an inpatient stay.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.  The patient presented to the hospital with intermittent fevers and a skin rash.  Reportedly, she had several encounters with her primary care physician and also evaluations performed in urgent care centers and received several courses of corticosteroids and antihistamines.

The patient developed drug-induced lupus.  However, there was no evidence that during the hospital stay the patient received any evaluation or treatment that necessitated admission at the acute inpatient level of care.  Despite an initial low-grade fever and mild bradycardia, the patient remained hemodynamically stable.  The tachycardia significantly improved after the administration of intravenous fluids.

There was no evidence of an underlying infection that would require the administration of intravenous antibiotics.  There was no need for long-term administration of intravenous corticosteroids.  Even though the patient had a minimal elevation of the creatinine level, it did not rise to the definition of acute kidney failure and did not require any additional treatments besides short-term administration of intravenous fluids.

Taking into consideration all of this information, it was reasonable to rule out an infection as the reason for the symptoms and to determine the plan of treatment going forward.  However, neither the severity of the patient's condition nor the complexity of services provided rose to the inpatient level of care.  There was no clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care. Overall, she remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.