Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skin Infection
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned.

The patient is a woman with a history of end-stage renal disease with dialysis dependence, diabetes mellitus type 2, seizure disorder status post tracheostomy removal, and dysphagia with percutaneous gastrostomy tube. She presented to the Emergency Department (ED) for an emergency evaluation due to severe, persistent abdominal pain at her percutaneous gastrostomy (PEG) tube site.

The patient was admitted to the hospital due to concern for sepsis and was treated with IV (intravenous) antibiotics and stabilized. The patient was discharged.

Yes, the Inpatient admission was medically necessary.

The patient had a history of multiple ED (emergency department) visits and hospitalizations. During her most recent hospitalization for acute abdominal wall cellulitis complicated by pustular discharge, the patient had declined removal of the infected PEG (percutaneous gastrostomy) tube and left against medical advice (AMA).

On initial presentation, the patient was tachycardic (pulse of 133 beats per minute) and severely hypotensive (blood pressure down to 78/50 mmHg [millimeters of mercury]). On examination, the patient had abdominal tenderness to inflammation at her PEG (percutaneous gastrostomy) tube site.

Laboratory studies were remarkable for normocytic anemia (hemoglobin 10.8 g/dl [grams per deciliter] with MCV [mean corpuscular volume] 93.8), hyponatremia (sodium 134), elevated creatinine (6.8), transaminitis (AST [aspartate aminotransferase] 85), elevated alkaline phosphatase (390.5), and lactic acidosis (lactate 2.54). Electrocardiogram (ECG) demonstrated sinus tachycardia with heart rate measuring 122 beats per minute.

In the emergency department, the patient was administered intravenous cefepime and intravenous vancomycin. The patient required acute inpatient care for the management of severe, persistent abdominal pain and for acute abdominal wall cellulitis at PEG (percutaneous gastrostomy) tube site in a high-risk patient with end-stage renal disease and frequent ED (emergency department) visits/hospitalizations. The treatment course for the patient consisted of intravenous meropenem, intravenous vancomycin coordinated with dialysis sessions, wound culture, blood culture, CT (computed tomography) abdomen/pelvis, Infectious Diseases Consultation, and Nephrology Consultation with resumption of hemodialysis. CT (computed tomography) abdomen/pelvis demonstrated focal consolidation in the posterior left lower lobe suggestive of pneumonia.

Day three, the patient terminated her hemodialysis session early, attempted to elope. On day four, the patient's PEG (percutaneous gastrostomy) tube dislodged and the patient was transitioned to topical antibiotic ointment to the PEG (percutaneous gastrostomy) tube stump site.

The patient presented with severe abdominal pain that persisted after recently leaving against medical advice (AMA) from a recent prior hospitalization for acute abdominal wall cellulitis. She was found to be tachycardic and hypotensive with a tender, inflamed abdomen at her PEG (percutaneous gastrostomy) tube site. There was concern for acute abdominal wall cellulitis. Hence prompt therapy with intravenous antibiotics had to be initiated.

Admission to the hospital was appropriate due to the acuity of her presenting illness, need for inpatient interventions including intravenous antibiotics, hemodialysis, and infectious workup, and high risk for clinical complications including progressive skin and/or soft tissue infection, necrotizing fasciitis, septic shock, hemodynamic instability, multiorgan dysfunction, acute encephalopathy, electrolyte derangement, arrhythmia, and even death.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.