Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Kidney Failure/ End Stage Renal Disease (ESRD).
Treatment: Inpatient emergency admission.

The health plan denied Inpatient emergency admission.  The determination is upheld.

The patient is a female with a history of systemic lupus erythematosus (SLE), end stage renal disease (ESRD) on hemodialysis, diabetes mellitus (DM), and hypertension (HTN), who presented for evaluation of chest pain, shortness of breath, and abdominal pain. She presented with similar complaints the day prior but signed out against medical advice after she had undergone a dialysis treatment. The patient was unsure if it was a full dialysis treatment. She denied fevers, nausea, vomiting, diarrhea, or other complaints. She was afebrile with a blood pressure of 167/128 millimeters of mercury (mmHg), a heart rate of 78 beats per minute (bpm), a respiratory rate of 16 breaths per minute, and a pulse oximetry of 97 percent (%). On exam, she was mildly lethargic and not in any respiratory distress. Her electrocardiogram (EKG) showed sinus tachycardia and non-specific ST and T wave changes. Her labs showed a potassium of 4.5, a creatinine of 7.470, a brain natriuretic peptide (BNP) of 105,121, and a hemoglobin of 8.5. A chest x-ray showed right basilar pleural fluid, atelectasis or consolidation. She reported not having an outpatient dialysis spot at that time. She was admitted for dialysis, placed on oxygen for comfort, and her home medications were resumed. Dialysis was performed by nephrology during her admission. She had continued acute on chronic pain complaints during her hospital stay. Her pain management was difficult due to a side effect of lethargy, history of non-compliance, concern for possible substance abuse, and inconsistent reporting of pain. Her imaging studies noted hepatosplenomegaly, but no acute abdominal findings. Hematology was consulted and recommended repeat imaging after fluid status was optimized. A repeat computed tomography (CT) scan did not report splenomegaly. Her lower extremity imaging was unremarkable. Vascular surgery was consulted due to right arm fistula pain and planned for a fistulogram. Gastroenterology was consulted for ongoing abdominal pain and did not feel she required an inpatient testing or work up as the pain was chronic in nature. She reported pain with cannulation of her fistula for dialysis, so dialysis was aborted. The patient signed out against medical advice.
At issue is the medical necessity of the inpatient hospital admission.
The health plan's determination of medical necessity is upheld, in whole.
The requested health service/treatment of inpatient hospital admission was not medically necessary based on the documentation provided. The patient presented with shortness of breath, chest pain, and abdominal pain with a history of non-compliance with her dialysis treatments. She was hypertensive, but hemodynamically stable. She did not have hypertensive emergency, respiratory distress, or hypoxia. She did not have cardiac arrhythmias of clinical concern. She did not have severe electrolyte or metabolic abnormalities. She did not have a uremic encephalopathy, pericarditis, or bleeding. She did not have severe or persistent nausea or vomiting. She did not have acute pain requiring inpatient management. Her imaging did not reveal any findings which required inpatient management or monitoring. She did not require emergency dialysis and could have been managed at an alternative level of care.