Appeal type: Medical necessity
Decision: Upheld

This is a patient with a past medical history significant for asthma who presented to the emergency department (ED) complaining of generalized weakness, dizziness, fatigue, and myalgias. These symptoms had been going on for a month but had been worsening over the past 3 days. She also noticed her urine was darkening. She exercises regularly and last worked out 4 days prior. She saw her primary care physician (PCP) with the above complaints a day earlier and blood work was drawn. Her total creatine kinase (CK) was 4,500 and she was advised to come to the ED. 

In the ED, her vital signs were normal and stable. Her exam was normal except for bilateral calf tenderness. Her abnormal blood work included a CK that had now increased to 5,863 and her aspartate aminotransferase (AST) was elevated at 119. Her urine toxicology was positive for tetrahydrocannabinol (THC). Her renal function and electrolytes were within normal limits. 

She was given 2 liters of intravenous (IV) fluids in the ED and admitted to the hospital for rhabdomyolysis. She was started on IV fluids at 150 milliliters per hour (mL/hr). She remained on intravenous fluids (IVFs) during her entire stay. Her CK decreased to 3,111 the next day and her myalgias improved. Her renal function remained stable. Her CK was down to 1,300, her renal function remained stable, and she was discharged home in stable condition. 

The health plan's determination is upheld. 

During the admission, she was started on IV fluids at 150 mL/hr. She remained on intravenous fluids (IVFs) during her entire stay. Her CK decreased to 3,111 the next day and her myalgias improved. Her renal function remained stable. Her CK was down to 1,300, her renal function remained stable, and she was discharged home in stable condition. 

She does not meet Milliman Care Guideline (MG-MD) for Rhabdomyolysis as there was no associated acute renal failure, inability to maintain oral hydration, altered mental status that was severe or persistent, or an electrolyte abnormality that remained after emergency or observation level of care. Also, even though the patient remained on IV fluids, there was no evidence that there was a need for this beyond the emergency room (ER) or a lower level of care. The patient was symptomatically improving, her CK was trending down, and her renal function remained stable on hospital day 2, and thus, she could have safely been discharged at that time. 

According to an article in the Journal of the American Medical Association (JAMA) from 2013 titled "Score for Kidney Failure or Mortality in Rhabdomyolysis." This was a study over 11 years that involved 2,371 patients in 2 large teaching hospitals in the Boston area. The inclusion criteria were patients at least 18 years of age and with a total CK of greater than 5,000. A score was determined based on age, sex, and lab values. Given her age, normal creatinine, and normal electrolytes, her risk score of having a rapid response called or in-hospital mortality was less than 1%. It was felt that with this risk score, a patient could be safely given IV fluids and discharged from the ER with close follow up for repeat blood work.