Diagnosis: Acute kidney injury

Treatment is an inpatient admission

The insurer denied coverage for

The denial is overturned

This is a patient with a history of osteoarthritis of the right hip, benign prostatic hyperplasia (BPH), hypertension, cardiac surgery, and left hip surgery. He presented to the hospital and underwent a right hip resurfacing procedure. He received 24 hours of prophylactic antibiotics post-operatively. He was found to have an acute kidney injury and elevated creatinine. He was given a fluid bolus and maintenance fluids. A renal ultrasound was negative for hydronephrosis, and a renal consult was obtained.

The medical records demonstrated a post-surgical event that required diagnosis and additional treatment. The patient was found to have AKI (acute kidney injury). He had undergone hypotensive anesthesia with subsequent decrease in renal function. His BUN (blood urea nitrogen) and Creatinine became elevated. He required monitoring and additional treatments beyond the normal post-surgical management of hip arthroplasty. Subspecialty consultations were requested. Changes in medications were required and additional laboratory tests were ordered. He also underwent diagnostic studies to assist in determining the etiology of his kidney problem.

These services could not be completed at a lower level of care. The inpatient stay was substantiated by his clinical condition and course.

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

The insurer's denial of coverage for an inpatient admission is overturned. Medical Necessity is substantiated.