Appeal type: Medical necessity
Decision: Upheld

Diagnosis:Genitourinary/Kidney Disorder
Treatment: Inpatient Hospital
The insurer denied: Inpatient Stay
The denial is: Upheld in whole

The patient is a female with a past medical history significant for hypertension, hyperlipidemia, anal cancer, and thyroid nodule who presented to the emergency department from home with complaints of dizziness, generalized aches, fever, and chills.
Her symptoms started one day before the presentation as dizziness and lightheadedness. On the day of her presentation, she began feeling fever and chills. The patient stated that she had a similar episode approximately two weeks before the day of admission. At the time, her symptoms resolved spontaneously.
The review of systems was negative for chest pain, palpitations, shortness of breath, cough, nausea, vomiting, diarrhea, dysuria, sick contacts, recent travel. The patient denied leg swelling or symptoms consistent with paroxysmal nocturnal dyspnea or orthopnea.
When the patient was seen by the admitting physician, she had a temperature of 101.3 Fahrenheit (F), respiratory rate 21, blood pressure 145/71, pulse rate 91 beats per minute (bpm), with oxygen saturation of 99% on room air. The patient was in no acute distress. The cardiovascular exam was unremarkable. Lungs were clear to auscultation bilaterally. The abdominal exam was unremarkable. On the neuro exam, the patient was able to move all four extremities. There were no focal deficits.
Laboratory evaluation revealed that white blood cell count was 2.1, hemoglobin 10.5, hematocrit 40.5, platelets 349. Sodium was 137, potassium 5.8, chloride 106, bicarbonate (HCO3), blood urea nitrogen (BUN) 10, creatinine 0.94, glucose 157. Chest x-ray demonstrated cardiomegaly. Urinalysis was negative for nitrite but had 25-50 white blood cells. Electrocardiogram (EKG) showed sinus rhythm with premature ventricular contractions in a bigeminy pattern.
The patient was admitted to the hospital with a diagnosis of urinary tract infection. Urine culture was sent, and the patient received treatment with Ceftriaxone.
Because of the premature ventricular contractions (PVCs) and bigeminy, cardiac monitoring was implemented.
The patient was continued on metoprolol, but lisinopril was held because of hyperkalemia.
In the hospital, the patient was seen by the infectious disease specialist who suggested that the patient might have a urinary tract infection. She was recommended to continue treatment with Ceftriaxone.
During the hospital stay the patient underwent a transthoracic echocardiogram, which demonstrated marked improvement in her left ventricular ejection fraction compared to the imaging studies performed two years prior.
While in the hospital the patient continued to complain of dizziness and unsteady gait. The patient reported that the room was spinning around when she got up. Treatment with Meclizine was initiated with significant improvement in her symptoms. MRI of the brain was performed to rule out stroke, and that study came back negative for any acute changes.
By the end of the hospitalization, the patient reported resolution of dizziness. She was able to ambulate without assistance. The patient was afebrile and hemodynamically stable and was discharged home.

The health plan's determination is upheld, in whole.

The inpatient stay was not medically necessary for this patient.
The patient presented to the hospital with complaints of dizziness, lightheadedness, and fever. Even though the patient had slightly abnormal urinalysis, the review of systems was negative for dysuria, increased frequency of urination, hematuria, urgency. There were no findings on the physical exam, including suprapubic tenderness or costovertebral angle (CVA) tenderness, which would have been suggestive of the presence of a urinary tract infection. The urine culture that was obtained at the time of admission remained negative throughout the hospitalization.
There is no evidence that the patient had a urinary tract infection severe enough to justify admission at the acute inpatient level of care.
At the time of admission, the patient was diagnosed with hyperkalemia, but in fact, the blood specimen was hemolyzed, and the subsequent serum potassium checks were within normal limits. The patient's fever resolved pretty quickly.  According to the progress note written the patient continued to be afebrile and hemodynamically stable.
Another clinical problem was PVCs and bigeminy. According to Merck Manual Professional Version online, "Ventricular premature beats (VPB) are single ventricular impulses caused by reentry within the ventricle or abnormal automaticity of ventricular cells. They are extremely common in both healthy patients and patients with a heart disorder. VPB may be asymptomatic or cause palpitations. Diagnosis is by electrocardiography. Treatment is usually not required."
Premature ventricular beats were an unlikely reason for the patient's symptoms. Her symptoms could have been related to benign positional vertigo, which actually responded to treatment with Meclizine.
Even though the patient had a fever and white blood cells in the urinalysis, there was no strong evidence of a urinary tract infection based on the patient's symptoms and results of the physical exam.
It was reasonable to admit the patient for a short period of monitoring and to conduct a workup of her symptoms. At the same time, there was no evidence that the severity of the patient's condition or the complexity of the services provided rose to the level of acute inpatient care.
The care could have been provided at a less acute setting.