Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ulcerative colitis

Treatment is an inpatient admission 

The insurer denied coverage for an inpatient admission 
 
The denial is overturned

This case involves a patient who had a history of ulcerative colitis. She presented to the hospital with a 2-day history of upper abdominal pain, weakness, and rectal bleeding. Vital signs noted temperature of 97.4  F (Fahrenheit), heart rate of 105, respiratory rate of 18, and blood pressure 97/61. Her oxygen saturation was 99% on room air. Laboratory results noted a white blood cell count of 10.9, red blood cell count of 4.06, hemoglobin of 6.5, and hematocrit of 24.3. Computed tomography of the abdomen and pelvis noted wall thickening and mild pericolonic stranding surrounding the ascending colon likely secondary to acute colitis. There was mild bowel wall thickening involving the distal sigmoid and descending colon with minimal pericolonic stranding likely secondary to the patient's known diagnosis of ulcerative colitis. There were prominent loops of small bowel measuring up to 2.8 cm (centimeters). A clear transition point was unable to be identified. However, it appeared to be in the mid abdomen. There were air-fluid levels within the more proximal small bowel loops. The appendix was partially air-filled and unremarkable. There was bilateral adnexal hypodensities with the largest measuring 1.9 x 2.0 cm on the right that was likely a hemorrhagic ovarian cyst. The bladder was fluid-filled and unremarkable. It was stated that the patient required a full hospital admission due to acute exacerbation of ulcerative colitis, rule out small bowel obstruction, and anemia.  She was admitted secondary to anemia that was most likely related to ulcerative colitis. She received an intravenous blood transfusion, intravenous fluids, laboratory testing, intravenous methylprednisolone, and a gastrointestinal consultation.  Blood pressures during transfusion were 99/60, 92/62, 94/63 pulse ranged from 77-85. Her discharge vital signs noted temperature 97.6 F, heart rate of 85, blood pressure of 94/63, and pulse oximetry of 100% on room air.

Per the MCG (Milliman Care Guidelines, an admission for inflammatory bowel disease is indicated for those with hemodynamic instability with vital sign abnormality that is not readily corrected by appropriate treatment, for severe signs and symptoms that has been insufficiently responsive to outpatient therapy (e.g., requires inpatient treatment such as IV (intravenous) immunosuppression), for signs of intestinal obstruction, for severe electrolyte abnormalities requiring inpatient care and for dehydration that is severe or persistent. Admission for anemia is indicated in the presence of significant clinical findings as indicated by tachycardia, altered mental status, heart failure, chest pain, exertional dyspnea, or other findings suggestive of inadequate perfusion when observation care treatment with transfusion her volume replacement is judged inappropriate due to severity of findings or has been ineffective. Based on the MCG guidelines, admission was medically necessary for this clinical scenario. As such, the denial of coverage for an inpatient hospital admission is overturned.

The insurer's denial of coverage for an inpatient hospital admission is overturned. Medical Necessity is substantiated.