Appeal type: Medical necessity
Decision: Overturned

This is a patient with a history of systemic lupus erythematosus, chronically corticosteroid dependent on prednisone 10 milligrams (mg) daily, who presented to the emergency department  with fevers and chills.  Reportedly, the patient experienced fevers and chills for over a week, as well as arthralgias and myalgias, shortness of breath, chest discomfort, and palpitations.  She also reported nausea, as well as diarrhea.  She was initially evaluated at another hospital where she was found to have a fever of 104 degrees Fahrenheit and was treated with broad-spectrum antibiotics vancomycin and azithromycin.  Her dose of prednisone was increased from 10 to 30 mg daily, but after 48 hours in the hospital, she left Against Medical Advice for no apparent reason.  She subsequently went to the current hospital with a persistent fever.  The temperature in the emergency department was 103 degrees, with a heart rate of 128, and a blood pressure of 101/67.  On exam, the patient did not appear to be in acute distress; the cardiac exam shows sinus tachycardia, tenderness to palpation in the lower abdomen, and clear breath sounds.  A venous blood gas was done in the emergency department.  She had an elevated lactate of 2.3 and leukocytosis of 11.3 with a hemoglobin of 9.9.  She had bandemia with 79% neutrophils.  The electrolytes were relatively stable, the cardiac troponin was normal.  A creatine phosphokinase (CPK) level was slightly elevated to 475, and a urinalysis was normal.  The patient tested negative for influenza.  A computed tomography (CT) scan in the emergency department revealed bibasilar atelectasis, but no significant intra-abdominal pathology, except for nonspecific fat stranding in the lower abdomen and upper pelvic region.  The chest x-ray was clear of infiltrates.  A transvaginal ultrasound was done in follow-up, which showed a moderate fundal uterine fibroid.  An obstetrics/gynecology (OB/GYN) consultant evaluated the patient on the day of admission and indicated that no intervention was necessary.
The patient was admitted to the hospital for a fever of unknown origin and possible lupus flareup.  Rheumatology was consulted, prednisone at an increased dose of 30 mg daily was continued, as well as the Plaquenil.  Blood cultures were obtained; the patient was started on broad-spectrum antibiotics, aggressive IV fluids, and an infectious disease consultation was requested.  For the chest discomfort, an echocardiogram was ordered.
After admission to the hospital, within 3 hours, a repeat lactate increased to 4.7 despite IV fluid administration. The patient was bolused with 2 liters (L) of normal saline, and a maintenance rate was increased to 200 milliliters per hour (mL/h).  At this point, IV vancomycin was added to broaden antibiotic coverage.  Every 4-hour lactate was ordered.  By the morning, the lactate decreased down to 1.8 with this regimen.  The infectious disease specialist evaluated the patient and noted an improvement in the vital signs, with a heart rate of 94, blood pressure of 108/67 and temperature of 97.8 degrees.  The white blood cell count had improved to 8.7 thousand (K), and the hemoglobin was still stable at 8.2.  The patient had a slight increase in the alanine aminotransferase (ALT) and aspartate aminotransferase (AST) on repeat labs.  The cardiac troponin remained negative.  However, the CPK values increased to 652.  The C-reactive protein came back at 109, and the procalcitonin was elevated at 0.69.  A viral polymerase chain reaction (PCR) panel came back negative.
The 2 dimensional (D) echocardiogram was done and showed an ejection fraction of 60-65% with no pericardial effusion or significant valvular problems.  Given the patient's immunocompromised state, infectious disease specialist recommended continuing vancomycin and Zosyn and following the blood cultures.  Rheumatology evaluated the patient as well, and recommended changing the corticosteroids to intravenous higher dosing, in case the cause of the patient's symptoms is systemic lupus erythematosus exacerbation.  They also discovered the patient has antiphospholipid immunoglobulin (Ig) M positive factors, which predisposes her to a hypercoagulable state; therefore, they recommended obtaining a computed tomography (CT) pulmonary angiogram to rule out a pulmonary embolus.  A lower extremity duplex was done, which ruled out acute deep vein thrombosis (DVT).  A pulmonary embolus was also ruled out with a CT angiogram.
Over the next two days, the blood cultures continue to remain negative, while the patient was treated with broad-spectrum antibiotics, IV corticosteroids.  IV fluids were maintained at a rate of 125 mL/hr.  She remained afebrile with an improved heart rate of 84 and borderline blood pressure of 99/61.
The health plan's determination is overturned.
The patient presented to the hospital with severe sepsis, of an unclear source.  She had a fever, tachycardia, leukocytosis, as well as elevated lactate despite early goal-directed medical therapy in the emergency department.  An elevated procalcitonin is highly suggestive of an infectious cause, which requires treatment with broad-spectrum antibiotics until the source is discovered.  A sepsis diagnosis requires an inpatient admission, especially in this patient population, with a rheumatologic disease on chronic corticosteroids, which represents an immunocompromised status.  There is an increased likelihood that the patient could have progressed to septic shock without continuing aggressive treatment, multidisciplinary team approach to stabilize her condition.
This type of presentation cannot be managed under a lower level of care, due to the high risk associated with sepsis in immunocompromised individuals.  The patient was appropriately admitted to inpatient status and treated in the hospital.