Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endocrine/Metabolic/Nutritional-Hyponatremia.
Treatment: Inpatient Hospital stay.
The health plan denied the inpatient stay as not medically necessary. 
The reviewer has overturned in whole the health plan's determination. 

The patient has a history of (h/o) urine fibroids, chronic anemia, and constipation. She presented to the emergency room (ER) with lightheadedness, dizziness, chills, nausea, vomiting and bilateral lower extremity edema. She was constipated and was drinking up to 4Liters (L) of water daily for the last one week to help with the constipation. In the ER she was hemodynamically stable. She had a systolic murmur. Labs showed a sodium (Na) of 126, hemoglobin (Hb) 9.1. Lower extremity doppler was performed for lower extremity edema and it was negative for a deep vein thrombosis (DVT). Her electrocardiogram (EKG) showed T-wave inversion in V2, and V3. She was initially given dextrose 5% and water (D5W) but was subsequently placed on 1000 - 1.5 L fluid restriction. Her blood glucose was low at 64 on admission that improved with intravenous (IV) D5. Her Na was slowly corrected and once her symptoms improved, she was discharged home with a plan to follow up with primary care physician (or provider) and gynecology.

Yes, the inpatient admission was a medical necessity due to symptomatic hyponatremia that was moderate in severity. Due to the unknown duration of her low Na, a slow correction of Na levels was necessary. This is typically done at the rate of 6-7 milliequivalents (meq) over 24 hours.
This is a patient with h/o urine fibroids, chronic anemia, and constipation. She presented to the ER with lightheadedness, dizziness, chills, nausea, vomiting and bilateral lower extremity edema. She was constipated and was drinking up to 4L of water daily for last one week to help with the constipation. She was found to have symptomatic hyponatremia in the emergency department. The etiology of her hyponatremia was excessive free water intake. She was hemodynamically stable. Exact timing of hyponatremia onset was not clear, and it was not certain that if the patient's hyponatremia started 48 hours prior to presentation or within 48 hours (as this will determine the chronicity of the hyponatremia and the management differs [1]. It is also important to note that she had hyponatremia of moderate severity (121 - 130) and in patients who are symptomatic and have moderate to severe hyponatremia, inpatient management is recommended as the patients who have sub-acute to chronic hyponatremia ( greater than (>)48 hours onset), a very slow correction of Na (at the rate of 6-7 meq over 24 hours) is recommended as very fast correction can lead to central pontine myelinosis [2,3]. Therefore, the inpatient admission in symptomatic patients with hyponatremia is recommended [3]. Per Milliman Care Guidelines (MCG) Health Inpatient & Surgical Care 25th Edition Electrolyte Disorder: Common Complications and Conditions, the inpatient admission is recommended in patients with Na less than (<) 130 and the patients who are symptomatic [4]. Both conditions are met in this patient. The patient was not suitable for a lower level of care as rapid correction of Na can lead to permanent pontine myelinosis.