201907-118965
2019
Healthfirst Inc.
Medicaid
Genitourinary/ Kidney Disorder
Inpatient Hospital
Medical necessity
Upheld
Case Summary
This is a case of a female with end-stage hemodialysis on schedule Monday, Wednesday, Friday through a left upper extremity arteriovenous (AV) fistula, who presented to the emergency department with multiple bouts of what she describes as fever and chills, occurring during dialysis, with rapid resolution after dialysis. The symptoms were improved by taking Tylenol. This type of episode occurred during the past several dialysis rounds, and when she informed her nephrologist of it, she was referred to the emergency department to be evaluated. The symptoms did not occur at all during times when the patient is not receiving hemodialysis. Other associated symptoms include slight rhinorrhea, and mild suprapubic pain. She also complained of chronic shortness of breath. The patient denied any sick contacts.
The patient was admitted to the hospital for fever of unknown origin, consideration was given to possible sepsis of unclear source, reaction to hemodialysis versus other. The patient was started on empiric antibiotic regimen with intravenous (IV) Zosyn. She was seen by nephrology, who recommended obtaining blood cultures and scheduling for dialysis while hospitalized. On the following day, the patient developed 6 or 7 bouts of watery stool, consistent with diarrhea. Stool sample was sent, which came back 24 hours later, positive for rotavirus. Clostridium (C.) difficile was negative. The patient's symptoms improved. She tolerated hemodialysis. No further fevers are recorded in the medical record. Daily labs, including chemistry panels, were obtained and were typical for a patient on hemodialysis. White blood cell count remained normal; vital signs remained normal, and all of the blood cultures and urine culture remained negative. The diarrhea was treated with loperamide and resolved, as did the suprapubic tenderness. The patient tolerated hemodialysis without difficulty and was eventually discharged to home in stable condition, without the need for further antibiotic therapy.
The health plan's determination is upheld.
The patient was evaluated for possible causes of infection, given the low grade temperature. A typical evaluation would include monitoring the temperature curve and looking for signs of sepsis. This patient did not satisfy the criteria for sepsis. In the absence of clear sepsis criteria, the patient can be monitored at a lower level of care status, with blood cultures, empiric antibiotics and monitoring of vital signs. Patients with ESRD will have abnormal creatinine, lactate, and electrolytes, which is controlled by performing hemodialysis treatments. Viral gastroenteritis caused by rotavirus can also produce all of the patients symptoms and certainly does not require inpatient admission. This hemodynamically stable patient could have been appropriately evaluated and treated at a lower level of care status.