Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status post cholecystectomy and appendectomy

Treatment inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld

The patient has a past medical history of hypertension, hypothyroidism, gastric bypass, cerebral vascular accident (CVA), hyperlipidemia, spinal fusion, and left ventral hernia.  The patient presented to the emergency department with abdominal pain that had been going on for a long time.  The physical examination revealed the left lower quadrant was mildly tender to palpation.  The patient ambulated with a steady gait without an assistive device.  The patient had intermittent lower abdominal pain associated with nausea and soft stools.  The patient reported worsening back pain after a fall a few weeks before the visit to the emergency room.  The provider had low suspicion for small bowel obstruction.  The patient had 5/5 strength.  The patient was admitted. Cardiology, bariatric surgery, and a gastrointestinal provider were consulted.  The gastroenterology surgeon noted the patient was status post cholecystectomy and appendectomy.  The computed tomography (CT) of the abdomen and pelvis showed a stable ventral abdominal wall hernia status post repair and gastric bypass status.  There was evidence of gastro-gastric fistula.  The rest of the examination showed no other significant abnormalities.  The provider recommended stool studies.  The provider also noted that the patient may require colonoscopy and possible upper endoscopy pending the results of the testing.  The C. difficile (Clostridium difficile) was negative.  The patient was discharged home.  The patient was to follow-up as an outpatient for possible endoscopy.

The patient showed no toxicity or laboratory elevation like white blood count (WBC), end organ damage like elevated liver function tests (LFT) or blood urea nitrogen (BUN)/Creatinine, active bleeding in the setting of her normocytic normochromic anemia. She could have been managed with monitoring, intravenous fluid, administration of pain meds in an ambulatory or outpatient status management and not jeopardize her care. The patients that need hospitalization are those with the following signs and symptoms:  Volume depletion/dehydration, altered mental status, significant rectal bleeding, prolonged symptoms (more than a week), severe abdominal pain, comorbidities such as human immunodeficiency virus (HIV) and diabetes (immunocompromised status), age, recent hospitalization or antibiotics, pregnancy, or weight loss.  There was no fever or severe abdominal pain requiring hospital admission rather than ambulatory setting such as observation. Lab data showed mild acid/base derangement, no electrolyte discrepancy, or renal impairment that needed acute hospital inpatient admission status.  Hydration, intravenous pain medications, and monitoring in ambulatory setting was appropriate for this patient and would not have jeopardized his well-being.  Acute admission to inpatient stay was not warranted.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.

The inpatient hospital admission not considered medically necessary for this patient.

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical Necessity is not substantiated.