Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  AKI (acute kidney injury).
Treatment:  Inpatient Hospital Admission.

The insurer denied the Inpatient Hospital Admission.  The denial is upheld.

The patient is an adult male who had a liver transplant earlier this year. As per Letter to the hospital on the patient presented for routine follow up and was found to have AKI (acute kidney injury) with creatinine spike to Cr (creatinine) 2.43 (1.8 two months earlier) as well as new elevation in transaminases to AST (aspartate aminotransferase) 83, ALT (alanine aminotransferase) 106. He denied any urinary complaints, diarrhea, or vomiting. The patient's Iabs revealed supratherapeutic FK (Prograf) level (21.1), deemed most likely the culprit for transaminitis. Treatment required withholding Prograf, appropriate IV (intravenous) fluid hydration, serial monitoring of creatinine and FK (Prograf) with appropriate adjustment in immunosuppression by level, continued MMF (mycophenolate mofetil) and prednisone treatment, and close monitoring of I/O (inputs/outputs).

The health plan denied coverage of the inpatient admission on the basis of medical necessity. The denial was appealed with the position that this patient was deemed high risk for short-term adverse events and acute level close monitoring to allow for rapid evaluation and treatment was needed. The contention is that the level of treatment and monitoring required could not have been safely and effectively provided in the outpatient or observation level of care setting and that inpatient admission was warranted and appropriate in this case.

The Inpatient Hospital Admission was not medically necessary.

On the day of admission, this patient did not meet from the MCG (Milliman Care Guidelines) National Guidelines long list of indications for a General Hospital Admission or any of the criteria for an admission, which includes VS (vital signs) hemodynamic instability, such as sepsis or respiratory distress. This patient presented with immunosuppression tacrolimus toxicity and the associated sequella. As per the MCG (Milliman Care Guidelines) National Guidelines, this patient could have been placed on Observation Care: "Other condition or finding (eg, laboratory test, imaging study, sign, symptom) that suggests a need for continued care, as indicated by 1 or more of the following: Acute need to establish diagnosis (eg, repeat or continued testing or clinical assessments are needed)".  This is consistent with the Letter of Appeal that noted, "[The patient] presented to the hospital for routine follow up and was found to have AKI [acute kidney injury] with creatinine spike to Cr [creatinine] 2.43 (1.8 two months earlier) as well as new elevation in transaminases (AST [aspartate aminotransferase] 83, ALT [alanine aminotransferase] 106). He denies any urinary complaints, diarrhea, or vomiting. Labs revealed supratherapeutic FK [Prograf] level (21.1) deemed most likely the culprit for transaminitis. Treatment required withholding Prograf, appropriate IV [intravenous] fluid hydration, serial monitoring of creatinine and FK [Prograf] with appropriate adjustment immunosuppression by level, continued MMF [mycophenolate mofetil] and prednisone treatment, and close monitoring of I/O [inputs/outputs]. This patient was deemed high risk for short-term adverse events and acute Ievel close monitoring to allow for rapid evaluation and treatment as needed."

All the above medical care, including adjusting and monitoring immunosuppression medication, serial laboratory testing, and monitoring of fluid status could have been safely, effectively, and efficiently performed as Observation Care, not requiring a full inpatient admission.