Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Erythroderma.
Treatment:  Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is overturned.

This is a male patient with a past medical history significant for biopsy-proven psoriasis, who presented to the hospital with erythroderma accompanied by subjective chills. He was seen in the dermatology office on the day of admission and was referred to the emergency department for initiation of cyclosporine. The review of systems was negative for a headache, weight loss, upper respiratory infection symptoms, sore throat, dysphasia, chest pain, palpitations, dyspnea, and abdominal pain.

The patient was in no acute distress. He was awake, alert, and oriented times 3. The patient looked uncomfortable due to pain. The neck was supple without lymphadenopathy, masses, jugular vein distention (JVD), and carotid bruits. The patient's lungs were clear to auscultation without wheezes, rales, or rhonchi. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. The abdomen was soft, non-tender to palpation, with normal bowel sounds, without guarding or rebound. The skin exam revealed diffuse erythema. The rest of the physical exam was unremarkable.

In the hospital, the patient was seen by a dermatologist, who stated that the patient received treatment with Prednisone daily and also received a dose of Taltz. Therefore, the plan was to obtain pre-Cyclosporine initial blood work including a comprehensive metabolic panel (CMP), uric acid, magnesium, and lipids, and to initiate treatment with Cyclosporine while monitoring blood pressure.

During the hospital stay, the patient received oral Cyclosporine. The first dose was administered. Subsequently, due to abnormal liver function tests (LFTs), the doses of Cyclosporine were down titrated but eventually were brought up again due to worsening erythema and pruritus.

During the hospital stay, the LFTs were monitored frequently. The elevation of transaminases was attributed to the potential adverse effect of Cyclosporine. In the hospital, the patient was seen by an ear, nose, and throat (ENT) specialist due to decreased hearing out of the left ear. The left ear canal was cleaned and suctioned. Debrox eardrops were utilized.

During the hospital stay, the patient remained afebrile and hemodynamically stable. The patient was transitioned to outpatient care. At issue is the medical necessity of an inpatient stay.

The hospital stay was medically necessary for this patient at the acute inpatient level of care.

The patient was admitted to the hospital due to severe erythroderma. Erythroderma is defined as erythema that covers more than 70 percent (%) of the body surface area. There are various skin disorders that can result in erythroderma. In this particular case, the erythroderma was related to psoriasis.

Treatment of the erythroderma includes treatment of the underlying disorder along with the following measures:  1) Supportive care (eg, rehydration, treatment for electrolyte abnormalities), 2) Topical care (e.g., emollients), and 3) Sometimes topical or systemic corticosteroids.

Regardless of the specific etiology, the initial management involves:  1) Assessment, active management, and ongoing monitoring of the hemodynamic status, 2) Replacement of fluid and electrolytes, 3) Assessment and management of skin, 4) Assessment and management of oral mucosa, eyes, genitourinary tract, 5) Monitoring of body temperature, 6) Nutritional support, 7) Treatment of cutaneous superinfections, and 8) Symptomatic treatment of skin inflammation and pruritus.

In this particular case, the patient required admission to the hospital to start treatment with Cyclosporine, watch for side effects, perform frequent laboratory monitoring, and for assessment of clinical response to treatment.
 
The patient had widespread erythroderma that required treatment with cyclosporine and necessitated frequent laboratory evaluation, watching for side effects, and frequent assessment of clinical response. The care could have been provided in the most efficient way only in the acute inpatient setting. The severity of the patient's condition, close monitoring of clinical response, and side effects justified admission at the acute inpatient level of care.