Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female who presented to the emergency department (ED) with eight out ten pain in the abdomen associated with dysuria and diarrhea.  She has a history of a fibroid uterus and anxiety.  Her evaluation revealed a diffusely tender abdomen with some guarding.  Blood work revealed mild elevation in white blood cell count.  Urinalysis revealed protein, ketones, and bacteria.  She had imaging with an ultrasound and computed tomography (CT) scan which revealed an enlarged fibroid measuring 10.9 to 12.2 centimeters (cm) as well as a right ovarian cyst measuring 5.4 centimeters.  There was no fluid in the pelvis.  A gynecology consult was obtained.  

The patient was admitted for pain control.  The differential included a degenerating fibroid versus ruptured ovarian cyst.  She was given intravenous fluids, intravenous Dilaudid, and intravenous Toradol.  Her pain improved and by the next day her pain was managed with ibuprofen and Tylenol.  She was tolerating a diet.  She did have repeat blood work which revealed a normal white blood cell count and mild anemia.  She was discharged home with follow-up with a gynecologist in one week.

The proposed inpatient admission was not medically necessary.
According to the American Medical Association, "Concerns regarding the admissions status of patients undergoing short hospital stays intensified in recent years as these stays became targets of Medicare recovery audit contractor (RAC) reviews and the use of observation status as an alternative to inpatient admission increased exponentially. Observation care is described by the Medicare program as a well-defined set of clinically appropriate services that includes short- term treatment, assessment and reassessment before a decision can be made as to whether a patient can be discharged or requires further treatment as an inpatient.  The distinction between inpatient versus observation status is not always clear-cut. Patients undergoing short hospital stays may be treated similarly to inpatients but classified as outpatients receiving observation services."

According to Centers for Medicare and Medicaid Services (CMS), "Under the two-midnight rule, established by the Centers for Medicare & Medicaid Services (CMS), hospital inpatient admissions are considered reasonable and necessary for patients whose stays cross two midnights, and these stays are payable under Part A. Stays expected to span less than two midnights under the rule are generally considered outpatient and therefore paid for by Part B."

In review of the medical record, the patient did require evaluation in the hospital.  However she did not have an acute abdomen nor was she hemodynamically unstable.  The interventions provided did not require inpatient level of care.  Serial abdominal exams and medication management could have been performed at a lower level of care such as observation.  An outpatient observation bed is an alternate level of healthcare compromising of short stay encounters for patients who require close nursing observation or medical management.  It is an area where the patient is observed and assessed to determine a need to be admitted to the hospital as an inpatient.  Therefore, the inpatient admission was not necessary.

The health plan did act reasonably, with sound medical judgment and in the best interest of the patient.