Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Kidney Injury
Treatment: Inpatient Admission
The health plan denied the requested inpatient stay. 
The health plan's determination is upheld.

The patient is a male with a past medical history significant for drug abuse, alcoholic pancreatitis, pancreatectomy, and splenectomy who was admitted to the hospital due to abnormal laboratory results. The patient presented to the hospital with complaints of nausea and vomiting.
Reportedly, the patient had elevated creatinine at 2.6. The patient was transferred from an outside emergency department (ED) for surgical evaluation. Reportedly, he underwent a hernia repair.
Over the course of several days before this admission, he complained of abdominal pain, nausea, vomiting, and diarrhea. At the time of the initial evaluation in the emergency department, he underwent a computed tomography (CT) scan of the abdomen and pelvis that demonstrated infiltration of the anterior abdominal wall, concerning for infection. The patient underwent a CT angiogram of the abdomen, which demonstrated no signs of mesenteric ischemia.
At the time of the initial evaluation, the patient was afebrile. His heart rate was 70 beats per minute, with a blood pressure of 153/93 millimeters of mercury (mmHg), a respiratory rate of 18 breaths per minute, and an oxygen saturation of 98% on room air. On exam, the patient had mild diffuse abdominal tenderness. The rest of the physical exam was unremarkable. Laboratory evaluation revealed that white blood cell count was 6.1, with a hemoglobin of 12.2, a hematocrit of 35.6, and platelets of 355.
The patient was treated with intravenous fluids and antiemetics and was initially kept nothing by mouth. Subsequently, he was started on a clear liquid diet, which he tolerated. A nephrology consultation was requested. The nephrologist suggested that the patient had acute kidney injury and recommended treatment with intravenous fluids. As a result of the treatment, his acute kidney injury resolved. In the hospital, the patient's diet was advanced, and the patient requested discharge home on his first hospital day.
The reason for abdominal pain was unclear, but acute gastroenteritis was thought to be the most likely diagnosis. His pain was manageable, and the patient tolerated liquids. The patient was discharged from the hospital on the day of admission.
At issue is the medical necessity for the inpatient stay.

I uphold, in whole, the health plan's determination of medical necessity.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care. The admission to an alternate level of care would have been the most appropriate, considering the clinical circumstances.
The abdominal pain was not associated with hemodynamic instability or peritoneal signs. Even though the patient was administered parenteral pain medications initially, his abdominal pain improved, and the patient did not need longer-term administration of parenteral analgesics.
There was no evidence that the abdominal pain was the result of serious medical conditions such as aortic dissection, bowel perforation, bowel ischemia, visceral organ torsion, or intestinal obstruction. There was no mention that the abdominal pain was associated with bacteremia or toxic megacolon. The evaluation of the abdominal pain did not require the patient not to eat or drink for an extended period of time. The acute kidney injury that was present at the time of admission resolved within a short period of time after receiving treatment with intravenous fluids.
Therefore, I could not see a legitimate reason why the severity of the patient's condition or the complexity of the services provided rose to the acute inpatient level of care.
Admission for observation at an alternate level of care would have been absolutely justified to ensure recovery of the kidney function, for serial abdominal exams, and to rule out a serious medical condition.