Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Urinary Tract Infection.

Treatment: Inpatient hospital admission.
 
The insurer denied the inpatient hospital admission.

The denial was overturned.

This is a female patient who was admitted to the hospital for suicidal ideation. The patient was started on Luvox and Lamictal. The patient had depression and psychosis. The patient developed a urinary tract infection (UTI) and was started on Bactrim. The patient's baseline white blood cell (WBC) count was 6730 and platelet count was 175,000. The patient developed a rash, neutropenia and thrombocytopenia on her new medications which were stopped; the patient did not develop fever or bleeding.  The patient had 1:1 sitter observation. The patient's white blood cell (WBC) count fell to 1.93 with platelets 79,000 and slowly improved without the addition of folate or myeloid growth factors. The patient did not develop anemia. The patient's total iron binding capacity (TIBC) and B12 levels were normal. The patient developed increased liver function test (LFT). The patient's liver ultrasound was benign, and her hepatitis panel was negative. With clearly improved lab counts and psychiatric clearance, the patient was discharged. The patient's two psychiatric medications were restarted upon discharge.

Per Bakchoul, T. et al. (2018), "Many drugs have been implicated in drug-induced immune thrombocytopenia (DITP). Patients with DITP develop a drop in platelet count 5 to 10 days after drug administration with an increased risk of hemorrhage. The diagnosis of DITP is often challenging, because most hospitalized patients are taking multiple medications and have comorbidities that can also cause thrombocytopenia. Specialized laboratory diagnostic tests have been developed and are helpful to confirm the diagnosis. Treatment of DITP involves discontinuation of the offending drug. The platelet count usually starts to recover after 4 or 5 half-lives of the responsible drug or drug metabolite."

Per Moore D. C. (2016), "Drug-induced neutropenia is a potentially serious and life-threatening adverse event that may occur secondary to therapy with a variety of agents. Cytotoxic chemotherapy can cause a predictable and dose-related decrease in neutrophil count. Neutropenia secondary to other medications tends to be an idiosyncratic reaction either as an immune-mediated reaction or because of direct myeloid cell line damage. This effect has been associated with a variety of medications including, but not limited to, clozapine, dapsone, methimazole, penicillin, rituximab, and procainamide."

Based on the review of the medical record and literature, inpatient admission was medically necessary for this patient. The patient had active suicidal ideation that required 1:1 sitter observation during inpatient stay. In this setting, the patient's psychiatric medications needed to be discontinued due to decreased cell count including platelets and white blood cell (WBC) count. With this patient's leukopenia and thrombocytopenia, the patient was at the risk for neutropenic fever and fever, respectively. The patient was also at risk for suicide with her active suicidal ideation and psychiatric instability off her offending psychiatric medications.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.
                                                 
Based on the above, the medical necessity for the inpatient hospital admission is substantiated.  The insurer's denial should overturned.