Acute Kidney Failure denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.1 criteria for RTC services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. For dimension 1, the patient demonstrated post-acute withdrawal symptoms of cravings, anxiety, insomnia, and tremulousness. The patient’s withdrawal needs can be safely met in a level 3.1 setting.

A 61-year-old male enrollee has requested authorization and coverage for Acthar, 80 mg subcutaneously, twice per week for treatment of the enrollee’s renal insufficiency status post right nephrectomy. Findings: The physician reviewer found that the cause of this patient’s nephrotic syndrome is not known with certainty because the patient has not had a kidney biopsy. However, it seems likely that this patient has FSGS secondary to hyperfiltration with a solitary kidney, in the setting of hypertension, despite being well controlled. This is a relatively common occurrence in patients with underlying renal risk factors, specifically hypertension, in patients who have a solitary kidney. Typically these patients do not respond to any immunosuppressive medications as it is not an immune-mediated process.

Where the denial was upheld

Findings: The physician reviewer found that the patient’s parent has requested reimbursement for inpatient hospital admission. Acute gastroenteritis is a major problem worldwide, representing one of the leading causes of morbidity and mortality in children under five years of age. Most cases are caused by viruses, are self-limited, and require supportive treatment. Oral rehydration therapy is the treatment of choice, particularly where diarrhea is the prominent feature and dehydration is mild to moderate. Intravenous (IV) rehydration is indicated when oral rehydration fails or when output is excessive. Vomiting limits the success of oral rehydration, prompting the use of anti-emetic medications. In this case, the patient, a male infant, presented with acute vomiting, diarrhea, and fever, with poor intake and decreased urine output.

The patient is a 68-year-old man with a history of renal failure due to obstructive uropathy, which is likely due to a history of a long-standing enlarged prostate. He wishes to have a kidney transplant. The transplant team recommends he have urologic evaluation, and possible transurethral resection of the prostate (TURP) to decrease the risk of obstructive uropathy effect on the possible kidney transplant. The patient notes he has seen urologists in the past who have recommended he have a TURP procedure, but he has always refused. The patient believes his kidney failure is due to salt overload and he is attempting exercises to help his prostate. The patient does not wish to undergo a TURP procedure as recommended by his provider. He wishes to be listed for kidney transplant without urologic clearance.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving acute kidney failure, then check the rights and deadlines that apply to your plan.