Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fever.
Inpatient Hospital.
The insurer denied the inpatient hospital stay.
The determination is overturned.

The patient has a medical history of sickle cell disease, avascular necrosis of the distal femur ad proximal tibia, bilateral hip surgery, scoliosis with thoracolumbar fusion, and a history of acute chest syndrome requiring intubation, who presented to the emergency department with fevers, chills, malaise and lower back pain in addition to urinary urgency.
On presentation, she was febrile to 102.8 degrees Fahrenheit with a heart rate of 128, blood pressure 106/59, respiratory rate 18, and with oxygen saturation of 100% on room air. Her exam otherwise noted bilateral costovertebral angle tenderness. Labs resulted with a white blood cell count (WBC) of 13.5, Hemoglobin (HGB) 10.7 (baseline 10), platelets 205, sodium 138, potassiuim 3.9, blood urea nitrogen (BUN) 9, creatinine 0.6, elevated total bilirubin (T. Bili) of 5.8, lipase undetectable, troponin undetectable, elevated lactate dehydrogenase at 352, and with lactic acid normal. An influenza screen was negative. A urinalysis showed trace protein, negative nitrites, and small leukocyte esterase. A chest x-ray showed no acute process. In the emergency department, the patient was given a normal saline bolus, Tylenol, ceftriaxone, and azithromycin. The patient was brought into the hospital with concerns for sepsis secondary to pyelonephritis in addition to active hemolysis with an elevated lactate dehydrogenase (LDH) and T. Bili, and with plans for intravenous (IV) fluids, ceftriaxone, folic acid, hydroxyurea, and further laboratory monitoring.
The patient continued to be febrile to 101.5 degrees with tachycardia into the 120s, and blood pressure 115/52. She reported a migraine. Repeat labs resulted with white blood cell count (WBC) 15.3, HGB 9.4, and with liver function tests not repeated. All cultures were no growth. A renal ultrasound showed no abscess. The patient was note to have worsening anemia with HGB 8.7. Total bilirubin of 1.9, LDH 221. She was continued on IV fluids and IV ceftriaxone with ongoing need for monitoring for worsening hemolysis. The patient was feeling better, her hemolysis lab results were improved with hemoglobin 9.8, and she was subsequently discharged.
At issue is whether care at the inpatient level of care was medically necessary.
Inpatient care was medically necessary for this patient presenting with concerns for sepsis and clear evidence of hemolytic anemia who continued to have hemodynamic instability and concerns for ongoing hemolysis that persisted beyond a reasonable period of observation. This is a patient who presented with a urinary tract infection accompanied by concerns for sepsis with fever, tachycardia, leukocytosis, and with concomitant hemolytic anemia in the setting of sickle cell disease. She had persistent hemodynamic instability with concern for sepsis with fever and tachycardia in addition to concern for worsening hemolysis and drop in HGB placing her at risk of arrhythmias, shortness of breath, and required ongoing monitoring of labs, IV fluids, and IV antibiotics beyond a reasonable period of observation of 24-48 requiring inpatient treatment and assurance of safe discharge. Inpatient care for this patient with persistent hemodynamic instability after admission and worsening anemia beyond a reasonable period of observation was medically necessary.