Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infectious Disease. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission for medical necessity. 
The denial was upheld.

This patient is a male with a history of back pain, adjustment disorder, and spinal abscesses that required drainage, who presented from the nursing home with a fever of 103. The patient reported generalized malaise and fever, progressively worsening since the morning. 

He was currently receiving intravenous (IV) antibiotics via his peripherally inserted central catheter (PICC). The medical team evaluated the PICC, and it looked erythematous and slightly edematous to the touch, citing it as the likely source of the infection. Blood cultures were obtained in the emergency department, and the patient was started on empiric antibiotics. Previous cultures had shown methicillin-resistant staphylococcus aureus (MRSA). The patient was treated with IV cefazolin at home, for a duration of 35 days.

The vital signs on arrival included a normal temperature, pulse rate of 101, blood pressure of 102/68. The patient had a rash, erythema, and ulcer, though unclear on which body part.

The laboratory data revealed leukocytosis of 13.7 with a hemoglobin of 11.1 and normal platelets. Multiple imaging studies were obtained of the spine, which showed no definitive fractures or destructive bone lesions. There was an abnormal appearance of the lumbar (L)5 vertebral body; the radiologist recommended a computed tomography (CT) scan with contrast or a magnetic resonance imaging (MRI) scan. The chest x-ray did not show any major abnormalities.

The patient was admitted to the hospital with a principal diagnosis of sepsis, rule out osteomyelitis, and rule out infective endocarditis. He was started on broad-spectrum IV Zosyn and vancomycin, a 2 dimensional (D) echocardiogram was ordered, inflammatory markers and orders were placed to remove the PICC.

A duplex of the upper extremity was obtained, which showed a deep vein thrombosis (DVT) in the axillary and brachial veins and superficial thrombophlebitis in the basilic vein. This prompted a vascular surgery consultation. The vascular surgery team evaluated the patient and noted heart rates between 84 and 101, normal temperature, and normal blood pressures. The white blood cell count had steadily declined down to 9.6, electrolytes and renal function were stable. Lactic acid was normal. The blood cultures had not grown anything. The vascular surgery team recommended treating with therapeutic Lovenox with a 3-month duration therapy.

An infectious disease specialist assessed the patient, reviewed the laboratory and imaging studies, discontinued the Zosyn, and recommended continuing vancomycin and ceftriaxone. They also recommended continuing serial erythrocyte sedimentation rate (ESR) monitoring for response to treatment.

A midline catheter was inserted without complications. By this time, the blood culture was growing yeast, and his urine cultures were without growth. The 2D echocardiogram showed no major abnormalities. The infectious disease specialist started micafungin. The patient continued to complain of back pain, which was controlled with tramadol and Dilaudid. The broad-spectrum antibiotics were continued. The Infectious Disease specialist determined the patient would need 28 days of treatment with micafungin and 6 weeks of vancomycin.

The following day, the patient remained afebrile, with complaints of back pain. He denied any weakness or numbness in the legs and his left axilla pain was improved. In the evening hours, he developed a temperature of 100.4, and was treated with Tylenol.

Over the next 4 days, the patient continued to improve, remained on micafungin and vancomycin, while the yeast species' speciation was still pending.

Yeast was speciated as Candida albicans. An infectious disease specialist recommended avoiding replacing a PICC line due to an active history of drug abuse. They recommended a trial of oral fluconazole. By this time, the patient had completed the entire 6-week course of antibiotic treatment for discitis.

The vascular surgery team reassessed the patient and recommended transitioning the patient from subcutaneous Lovenox to Eliquis. The patient was cleared by infectious disease for discharge back to the nursing home. The following day, per case management notes, the patient preferred to go home with outpatient physical therapy instead of back to the nursing home. The medical team was able to discharge the patient home with a 1-week follow-up with the primary medical doctor.

At issue is the requested health service/treatment of inpatient stay for medical necessity.

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

No, the requested health service/treatment of inpatient stay is not medically necessary for this patient.

This patient, with known vertebral discitis, treated with IV antibiotic therapy, developed a DVT at the PICC catheter site. The catheter was removed, and the patient was started on anticoagulation, which does not require inpatient hospitalization. The documentation does not support damage of any deep vascular structures caused by the peripherally inserted central catheter. There is no evidence of catheter fracture, cardiac arrhythmias caused by the catheter, or surgical intervention necessary, for catheter removal.

On admission, the patient exhibited systemic inflammatory response syndrome (SIRS) criteria without evidence of severe sepsis or septic shock. Within 24 hours, the vital signs stabilized; hence sepsis was resolved. The patient grew out yeast from the blood culture. The evaluation for endocarditis was negative, based on the normal echocardiogram results. There was no evidence of ongoing sepsis or clinical deterioration. The patient had no alteration of mental status; he was not immunocompromised. The patient was appropriately treated with antifungal agents. The leukocytosis resolved, and the patient had no further complications of the current infection. There is no clear indication to continue to monitor the patient in the hospital while waiting for speciation and sensitivities of the yeast culture.

In conclusion, the requested health service/treatment of an inpatient stay was not medically necessary for this patient.