Diagnosis: Dehydration

Treatment: Inpatient admission

The insurer denied coverage for an inpatient admission

The denial is overturned

The patient was admitted for diarrhea and poor oral intake. BUN (blood urea nitrogen) / Cr (creatinine) on admission was: 80/3.5 (Cr baseline: 2). The patient was managed with IVF (intravenous fluids) and PO (oral) hydration as nausea and vomiting resolved on day 2 of admission. The patient's renal function improved to baseline with BUN/Cr of 20/1.5. A CXR (chest x-ray) and abdominal x ray showed no acute process.

The gold standard for the distinction between prerenal disease secondary to volume depletion and post-ischemic and nephrotoxic ATN (Acute Tubular Necrosis) is the response to fluid repletion per KDIGO (Kidney Disease Improving Global Outcomes) and National Kidney Foundation guidelines. If sufficient fluid is given to reverse any signs of volume depletion (e.g., hypotension, cool extremities, low urine-sodium concentration), return of the serum creatinine to the previous baseline within 24 to 72 hours is considered to represent a correction of prerenal disease, whereas persistent acute kidney injury (AKI) is considered to represent ATN, this patient's kidney function did not return back to baseline after adequate fluid challenge which is consistent with ATN.

ATN has higher risk for mortality which requires close monitoring of kidney function, electrolytes abnormalities and possible need for renal replacement therapy.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the full hospital admission is overturned. Medical Necessity is substantiated.