Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

The insurer has denied coverage for the hospital admission as not medically necessary. In a Final Adverse Determination letter, they stated that the patient was admitted for a recent gastric bleed. There was no low blood pressure, ongoing active bleeding, or other findings warranting an inpatient admission. The requested admission is denied based on Milliman Care Guidelines 26th Edition using the guideline of Gastrointestinal Bleeding, Lower, ORG: M-182.  

The hospital is appealing. In an appeal letter, it is stated that the patient presented to the emergency room (ER) with complaints of abdominal cramping. The patient was given an intravenous (IV) fluid bolus, IV Famotidine, and IV Ondansetron. The patient required acute inpatient care for the management of abdominal pain, diarrhea, and rectal bleeding. The care plan consisted of a Gastroenterology (GI) consultation, serial lab testing, and vital sign monitoring. Magnetic resonance cholangiopancreatography (MRCP) was done. The patient was discharged. The requested admission was warranted based on Milliman Care Guidelines using the guideline of General Inpatient Admission Criteria. 

The patient presented with abdominal pain and blood streaks in the stool. There was a history of a rectal prolapse. The patient was afebrile and the vital signs were stable. The abdominal exam was benign. There was no leukocytosis. A computed tomography (CT) scan showed questionable colonic wall thickening and a cystic abnormality in the pancreas. The lactate was normal. The hemoglobin was 12.9. It was determined that the patient was not actively bleeding. A magnetic resonance cholangiopancreatography (MRCP) was negative for a pancreatic mass. The bleeding stopped and there was no current evidence of a rectal prolapse. The patient was treated with Miralax. 

Medical necessity was determined based on Milliman Care Guidelines (MCG) 26th Edition guideline M-182 for Lower Gastrointestinal Bleeding. Clinical indications for admission include hemodynamic instability, ongoing active bleeding, failure to control bleeding after a colonoscopy, severe coagulopathy that is not reversible, anemia with signs of cardiac ischemia, peritoneal signs, and an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

This patient had a history of a rectal prolapse and developed constipation and rectal bleeding. There was no active bleeding, and no acute interventions were needed at this time. Miralax could have been given as an outpatient. The hemoglobin could have been monitored with observation status. The patient did not meet MCG criteria for admission for Lower Gastrointestinal Bleeding. The health care plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for the hospital admission is not substantiated.