Diagnosis: Sepsis

Treatment is an inpatient admission

The insurer denied coverage for an inpatient admission

The denial is overturned

The patient is an adult male who presented to the emergency department (ED) on with history of nausea, vomiting, abdominal pain and myalgias of 2 days duration. The patient also reported tea colored dark urine. The patient reported use of cannabis prior to this presentation.

At presentation Temperature of 98 degrees F (Fahrenheit), Heart Rate 110, Respiratory Rate 20, Blood Pressure 117/68 mm Hg (millimeters of mercury), oxygen (O2) saturations 97 % at room air. The patient was in some distress. Lungs were clear. The patient's white blood cell count (WBC) was 22.5K (thousand), hemoglobin (Hb) 17.9 BUN (blood urea nitrogen)/Creatinine (cr) 26/2.75 (Baseline Cr was normal).

Liver function tests (LFTs) were within normal limits (WNL), Lipase was elevated suggesting pancreatitis. Creatine phosphokinase (CPK) was elevated and peaked at 3537. Chest x-rays revealed (CXR) left infra hilar infiltrate. Urinalysis (UA) showed red blood cells (RBC) 50-100.

The patient was admitted for Sepsis rule out (R/O) pneumonia (PNA), Dehydration, Rhabdomyolysis and acute kidney disease (AKI). The patient was aggressively hydrated and treated with Rocephin and Azithromycin for PNA. He received PPI (proton pump inhibitors) and Zofran for nausea/Vomiting. A sonogram of the Kidney was done to R/O Obstruction.

The patient's CPK's continued to rise after admission. Creatinine slowly started decreasing.

This patient had multiple medical issues as described. He needed very close monitoring for his AKI and Rhabdomyolysis. Renal function was closely monitored with aggressive hydration. Once the patient improved, he was discharged home.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the hospital admission is substantiated.