Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sepsis syndrome due to Streptococcus pharyngitis
Inpatient Hospital
The insurer denied the inpatient hospital stay.
The determination is overturned.

The patient presented to the emergency department on with complaints of a fever, sore throat, productive cough, and decreased oral intake. Reportedly, she was evaluated previously for the same symptoms, and at that time a Streptococcus culture was obtained and came back positive. The patient was started on oral Azithromycin.
At the time of the initial evaluation in the emergency department the patient was afebrile. Her heart rate was 140 beats per minute (bpm), respiratory rate 24, and blood pressure 102/92. The patient was in moderate distress.
When the patient was seen by the admitting physician her temperature was 36.9 degrees Celsius, pulse 116, respiratory rate 20, blood pressure 92/71, and oxygen saturation 93% on room air. The patient was awake, alert, and oriented times three, in no acute distress. The head, eyes, ears, neck, throat (HEENT) exam was within normal limits except significant injections of the throat. The neck was supple without lymphadenopathy, masses, jugular vein distention (JVD), carotid bruits. The lungs were clear to auscultation without wheezing, rales, or rhonchi. The patient was tachycardic. The abdominal exam was unremarkable. The rest of the physical exam was within normal limits.
Laboratory evaluation revealed that her white blood cell count was 33.0 with 6% of bands and 81% of neutrophils. Hemoglobin was 15.1, hematocrit 43.8, and platelets 288. D-dimer was 1866. Sodium was 129, potassium 4.2, chloride 88, bicarbonate 20, blood urea nitrogen (BUN) 15, creatinine 1.8, and glucose 197. Total bilirubin was 2.1, and troponin was normal.
A computed tomography (CT) angiogram of the chest demonstrated no evidence of a pulmonary embolism. The lung fields appeared to be clear. A CT scan of the soft tissues of the neck was negative.
At the time of the initial evaluation, the patient was diagnosed with sepsis and received treatment with intravenous fluids. She received intravenous Toradol, Zofran, and Ceftriaxone.
The patient was admitted to the hospital with a diagnosis of sepsis syndrome due to Streptococcus pharyngitis and also acute kidney failure. During the hospital stay, the patient received treatment with intravenous fluids and intravenous antibiotics. She was started on a clear liquid diet.
Reportedly, on the next day after the day of admission the patient remained tachycardic. Her heart rate was in the range between 118-119 bpm, and the patient continued to receive treatment with intravenous fluids and intravenous antibiotics.
Since her clinical condition significantly improved, her kidney function and electrolytes normalized, and the white blood cell count came down, the patient was discharged home in stable clinical condition with a prescription for oral antibiotics. At issue is the medical necessity of an inpatient stay.
The inpatient stay between was medically necessary because the patient clearly had sepsis, which was a life-threatening condition if remained inadequately treated. According to the nationally accepted standards of care, the treatment of sepsis is provided at the acute inpatient level of care.  The systemic inflammatory response syndrome (SIRS), Sepsis, and Septic Shock Criteria is a risk stratification tool that defines the severity of sepsis and septic shock. Based on the calculations, the patient met sepsis criteria.
Her heart rate was greater than 90 bpm, a respiratory rate greater than 20 times per minute, white blood cell count was greater than 12,000/cubic millimeters (mm3). In addition, the patient had a Streptococcus infection.
Another risk stratification tool that is used in this clinical situation was the quick Sequential Organ Failure Assessment (qSOFA). The qSOFA score (also known as quickSOFA) is a bedside prompt that may identify patients with suspected infection who are at greater risk for a poor outcome outside the intensive care unit (ICU). It uses three criteria, assigning one point for low blood pressure (systolic blood pressure (SBP)less than or equal to [ <=]100 millimeters of mercury (mmHg)), high respiratory rate ( greater than or equal to [>=22] breaths per min), or altered mentation (Glasgow coma scale< 15).
In this clinical case, the patient received a total score of one, which is interpreted as a suspected infection with a 3% risk of a bad outcome. This prompts consideration that sepsis is possible. Sepsis is a clinical syndrome of life-threatening organ dysfunction caused by a dysregulated response to infection. Sepsis represents a spectrum of disease with mortality risk ranging from moderate to substantial (eg, > 40%) depending on the various pathogens and host factors along with the timeliness of recognition and provision of appropriate treatment.
In general, the treatment of sepsis includes perfusion restoration with IV fluids and sometimes vasopressors, oxygen support, broad-spectrum antibiotics, source control, sometimes other supportive measures.
In order to provide treatment for patients with sepsis in the most efficient way in a timely manner, the admission at the acute inpatient level of care was the most appropriate and was medically necessary.