Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Cardiac/Circulatory Problems - Other
Treatment:  Inpatient Hospital

The patient is a female with a past medical history significant for hypertension, hyperlipidemia, Crohn's disease, morbid obesity, bilateral mastectomy because of breast cancer, subsequent breast reconstruction surgery, and pericardial effusion who presented to the hospital with complaints of generalized weakness and fatigue.  Apparently the patient was hospitalized because of volume overload and pericardial effusion.  At that time, she was diuresed, and as a result, her pericardial effusion significantly decreased in size.
Approximately one week before the day of admission the patient started to notice nausea and lose/soft bowel movements, which were typical for her Crohn's disease.  She also noticed a yellow discharge from her chronic abdominal wound.  At that time the patient denied chest pain, palpitations, shortness of breath, dyspnea on exertion, syncope.
She also denied fever, chills, cough or mucus production, vomiting, hematemesis, bright red blood per rectum, melena.
On the physical exam, the patient was afebrile, respiratory rate was 17, blood pressure 93/62, heart rate 78, oxygen saturation 98% on room air.  The patient had a small superficial wound in the area of the right breast reconstruction.  The patient also had a wound in the lower abdomen/pelvis, which was described as a deep non-healing surgical wound with yellow drainage.
On the laboratory evaluation, white blood cell count was 15.4, hemoglobin 9.4, hematocrit 32.2, platelets 359.
Sodium was 142, potassium 4.8, chloride 104, blood urea nitrogen (BUN) 19, creatinine 1.4, glucose 99. Urinalysis had 9 white blood cells and a trace of leukocyte esterase. The lithium level was normal.
Computed tomography (CT) scan of the abdomen and pelvis was performed.  It demonstrated anterior abdominal wall postsurgical changes, soft tissue defect measuring 3.3 x 1.5 x 2.8 centimeter (cm). It showed extensive soft tissue stranding but no discrete fluid collection.  It also showed mild enterocolitis involving the terminal ileum and cecum. It demonstrated multiple mixed density splenic lesions, which were prominently hypodense with central enhancement. It also demonstrated moderate simple pericardial effusion.
The patient was admitted to the hospital with a diagnosis of presyncope and recently diagnosed pericardial effusion.  The patient received treatment with intravenous fluids while in the emergency department.  An echocardiogram was performed. Infectious disease consultation was obtained.  At the time of admission, the patient received treatment with intravenous Vancomycin and Zosyn.  In addition to treatment with antibiotics, the patient also received a stress dose of steroids because of concerns for possible adrenal insufficiency.  In the hospital, the patient was seen by a cardiologist.  The cardiologist reviewed the echocardiogram and stated that even though there was some pericardial effusion, there were no signs of cardiac tamponade.  No intervention was recommended.  The cardiologist suggested administering a dose of intravenous Lasix because the patient appeared to be a little bit volume overloaded, since she received the treatment with intravenous fluids initially because of low blood pressure.  The cardiologist suggested resuming Coreg in a lower dose.  It was mentioned that Coreg was initially held in the setting of hypotension.
In the hospital, the patient was seen by a general surgery service.  It was indicated that there was no surgical intervention required for splenic lesions seen on the CT. They recommended further evaluation by plastic surgery for breast reconstruction and abdominal wound site.
According to the discharge summary, while in the hospital the patient received treatment with intravenous antibiotics for abdominal wound infection and at discharge was switched to an oral antibiotic based on the wound culture growing Morganella morganii.

The health plan's determination is upheld.

While this patient had legitimate issues that would require admission to the hospital, neither the severity of the medical conditions nor the complexity of the services provided justified admission at the acute inpatient level of care.
This patient presented to the hospital with complaints of generalized weakness and fatigue.  At the time of admission, the patient was found to be hypotensive.  At the same time, it was unlikely that the hypotension was related to sepsis.
In order to see if the patient met sepsis criteria, systemic inflammatory response syndrome (SIRS), Sepsis, and Septic Shock Criteria was reviewed.  SIRS criteria are a risk stratification tool that helps to define the severity of sepsis and septic shock.
In this clinical situation, the patient did not meet the criteria for sepsis or septic shock. In this clinical context, it was very likely that the patient's hypotension was related to possible over diuresis due to the use of diuretics at home as well as the use of blood pressure medications.
This patient had a chronic abdominal wound related to the previous surgery.  There was some yellowish discharge from the wound described in the notes.  If there was real clinical suspicion that the patient had a significant wound infection that would require long term treatment with antibiotics, it was definitely reasonable to admit the patient to the hospital for monitoring and start the treatment with intravenous antibiotics while waiting for the culture results.
At the same time, there was no evidence that the patient required any intervention, surgery, or procedure to address the chronic wound and possible infection.
At the time of admission, the patient had very mild kidney insufficiency, which resolved very quickly.
During the hospital stay the patient was seen by general surgery for evaluation of splenic lesions that were noted on the computerized axial tomography (CAT) scan.  No interventions were done, and outpatient follow-up was recommended.
During the hospitalization, the patient was noted to be volume overloaded as a result of the treatment with intravenous fluids that were administered for possible sepsis.  The volume overload was treated with intravenous Lasix with a fast resolution of symptoms.  The patient's hypotension improved quickly with the administration of intravenous fluids.  This patient never required long-term administration of intravenous fluids, and in fact, received Lasix because of the volume overload.  There was no evidence that the patient required the administration of vasoactive agents because of the persistent hypotension.
Taking into consideration all these facts, the severity of the patient's condition and the complexity of the services provided did not justify admission at the acute inpatient level of care.
At the same time, the admitting physician had relevant concerns in regard to possible sepsis, a possible need for long term treatment with antibiotics, a possible need for evaluation of the splenetic lesions, and mild abnormalities of the kidney function.  All those issues needed to be addressed.  The evaluation and care could have been provided at a lower level of care status.