We received a denial on metabolic acidosis. Based on the review of the medical record, this dx was not clinically validated. Based on the insurance company criteria for metabolic acidosis:
Arterial serum pH reduced to less than 7.35 and serum bicarbonate concentration is abnormally low, often defined as less than 22 mEg/L (although the threshold may vary across laboratories)
Patient presented to the hospital with abdominal pain, nausea and vomiting due to SBO. Lactate level 2.9, no bicarbonate level less than 22 and no pH from ABG's less than 7.35. HCO3 remained at 24 during the hospital stay, no ABG's done. Lactate decreased to 2.1 approx. 7 hours after admission. No bicarb given, no additional monitoring noted.
Patient was treated with IVF's (D5 1/2NS with KCL) during the admission. Of note patient's Anion gap was 15.4
Question: Our supervisor is trying to flight/appeal this denial, because the CDI nurse that reviewed the chart is saying that this patient clearly has metabolic acidosis. Any thoughts on how this should be handled to flight/appeal the denial?... Any alternate criteria with tx to counter the criteria/tx the insurance company is giving?