Diagnosis: End Stage Renal Disease (ESRD)
Treatment: Inpatient Stay
The insurer denied: Inpatient Stay
The denial is: Overturned.

The patient is a female with a history of congestive heart failure (CHF), diabetes mellitus (DM), hypertension (HTN), cerebrovascular accident (CVA), post-traumatic stress disorder (PTSD), right eye blindness, and end stage renal disease (ESRD) on hemodialysis who presented due to worsening nausea, vomiting, abdominal pain, constipation, fatigue and shortness of breath in the setting of missing 5 dialysis sessions.
Her vitals showed that she was afebrile with a pulse of 89, a respiratory rate of 20, a blood pressure of 171/101 and a room air pulse oximetry of 100% (percent). On exam she was not in any acute distress, she had mild crackles in her lower lung fields bilaterally and no edema. Her labs showed a white blood cell (WBC) of 13.7, a hemoglobin of 12.6, a venous potential hydrogen (pH) of 7.14, a potassium of 3.6, a lipase of 571, a creatinine of 9.8, a blood urea nitrogen (BUN) of 95, and a carbon dioxide (CO2) of 11. She was started on intravenous (IV) bicarbonate and was admitted to inpatient medicine. Nephrology was consulted and she underwent urgent hemodialysis. A computed tomography (CT) scan showed no concerning findings. As her last outpatient hemodialysis (HD) session was noted to more than 30 days ago she lost her outpatient dialysis slot and required a new outpatient dialysis spot. She complained of left facial decreased sensation and a stroke code was activated which was negative. She was considered stable for discharge. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is overturned.

The patient presented with nausea, vomiting, and severe metabolic acidosis in setting of missed dialysis treatment. Importantly, the patient had lost their outpatient dialysis spot due to missed treatment and could not be safely discharged until a new outpatient dialysis spot was established. She required urgent hemodialysis on presentation due to her severe metabolic acidosis and then required continued inpatient monitoring and treatment while awaiting a safe discharge plan. The inpatient stay was therefore medically necessary.