Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stomach infection.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male that presented with a three day history of chest pain and breathing problems. The patient has a history of constipation and perforated sigmoid colon for which he required a colostomy in late 2019. The postoperative course was complicated by an intra-abdominal abscess, which required drainage by Interventional Radiology. The patient had three drains placed which subsequently were removed as outpatient. 

On presentation, the patient was afebrile with normal vital signs.  Labs included troponin levels were within normal limits and the white blood cell count was not elevated. EKG (electrocardiogram) was normal. The patient underwent CT (computed tomography) angiogram of the chest to rule out pulmonary embolus. The CT showed an abscess in the left upper quadrant of the abdomen measuring 2.1 X 3.5 cm and a small reactive pleural effusion. The fluid collection was consistent with that which had been diagnosed on a prior scan. 

The patient was admitted to acute inpatient level of care. The patient was ordered for intravenous fluids and antibiotics. Interventional Radiology was consulted for drainage of the abscess.  Interventional Radiology determined the small abscess was not amenable to drainage. 

No, the acute inpatient stay was not medically necessary. 

Myocardial infarction was also ruled out by EKG and troponin levels. The patient was ordered for intravenous fluids and antibiotics. The patient had a normal white blood cell count. 

Interventional Radiology was consulted for drainage of the abscess.  Interventional Radiology determined the small abscess was similar to the prior abscess noted the prior month and was not amenable to drainage. The patient felt better with no breathing problems. Pulmonary embolus and myocardial infarction had been ruled out. Regular diet was ordered. The patient was discharged home without antibiotics. The care rendered did not require acute inpatient level of care for the post-midnight stay.

The health plan's denial of the acute inpatient stay was reasonable and did not compromise the best interest of the patient. The patient presented to with chest pain in the postoperative period. There was concern that the patient may have suffered a postoperative complication namely a pulmonary embolism or myocardial infarction. The patient required to be ruled out for these conditions. CT angiogram done on the date of presentation essentially ruled out a pulmonary embolism. An incidental finding on the lower cuts of the CT showed a residual abscess in the left upper quadrant of the abdomen at the site where the patient had previously had drainage of an intra-abdominal abscess. The patient notably had no elevation in the white blood cell count and no fever. The patient was placed on intravenous antibiotics. Interventional Radiology, which was consulted on the date of presentation, could have determined that the abscess did not require drainage. In fact, the patient was not prescribed antibiotics when discharged the following day consistent with the fact that it was determined that the residual abscess was probably sterile from previous treatment. 

The care the patient would have received at a lower level would have been identical to that which was received. In fact, treatment at a lower level of care would not have compromised patient safety or the quality of care rendered. 

The hospital through its agent, accurately reiterates the patient history and concludes the admission was medically necessary and appropriate. The agent states the admission was necessary because the patient received intravenous antibiotics and Interventional Radiology was consulted for drainage (which they deemed unnecessary). The reasons cited due to substantiate an acute inpatient level of care. No reason is given as to why the patient could not have been treated at a lower level of care.