Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fever, Upper Respiratory Symptoms 
Treatment: Inpatient Stay 

The insurer denied the inpatient stay. The determination is overturned. 

This patient with a history of renal tubular acidosis (RTA) was brought in by ambulance accompanied by her mother. The patient had complaints of vomiting, coughing, headaches and a fever. The fever started 2 days prior and responded to tepid sponging at home. It was associated with a cough and runny nose also for 2 days. The mother reported that the cough sounded wet. Vomiting started the day prior, with 4 episodes. She presented due to an inability to keep anything down due to the vomiting. There was also an associated headache and reportedly a brother was sick at home. 

The patient was on home medications of potassium citrate and citric acid for her RTA. Per the mother, the patient also has a renal stone that was diagnosed on ultrasound six months prior. The last emesis was  approximately 6 hours prior to her presentation to the emergency room (ER). The mother reported that the patient had a normal urine output. The exam in the ER showed nasal discharge, moist mucous membranes (MMM) and no distress described. Labs were ordered as well as a chest x-ray (CXR) along with Zofran and a by mouth (PO) challenge. Labs revealed that the patient was influenza A positive, potassium was 2.9 and carbon dioxide (CO2) 16. It was reported that the patient failed a PO challenge and persisted with nausea so she was admitted for further management, IVF and correction of electrolyte imbalance. Also reported as reason for admission: Influenza A positive (+) associated with vomiting, poor oral intake. The exam documented on the history and physical (H&P) was normal. Blood pressure was (B/P) 105/73, heart rate (HR) 109, temperature 98.2 degrees, respiratory rate (RR) 20, and oxygen saturation (O2 sat) 100%. The patient was started on intravenous fluids (IVF) with potassium choride (KCl), sodium chloride (NaCl) and sodium acetate. On the next day of admission, the patient improved clinically. She was tolerating oral intake and a repeat basic metabolic panel (BMP) showed the potassium up to 3.4. She was then cleared for discharge home. 

At issue is the medical necessity of an inpatient stay. 

The requested health service/treatment of inpatient stay was medically necessary for this patient. This patient, with history of renal tubular acidosis on oral medications at home, presented with a fever, URI symptoms, and PO intolerance. In the ER she was treated with IVF as well and antiemetic medication but still persisted with nausea and emesis. Given her history of RTA, she was at higher risk of complication due to her underlying condition. With PO intolerance and most likely an inability to keep her oral medications down, her electrolyte imbalance may worsen causing marked metabolic acidosis or worsening hypokalemia. Admission for IVF with electrolyte replacement until she is able to tolerate her medications for her RTA as well as serial monitoring of her electrolytes would be acceptable care. She was in the ER for about 6 hours prior to being admitted. She did not respond to proper ER management, exemplified by PO intolerance and recurrent emesis, so admission was medically necessary.