Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. The insurer denied: inpatient stay. The denial is upheld in whole. 

The patient is a female who presented to the emergency department with concerns of right lower quadrant pain associated with nausea and diarrhea. Pertinent history included chronic leukocytosis followed by hematology/oncology, cholecystectomy, periumbilical hernia repair, and diverticulitis.
Initial vital signs revealed a temperature of 98.4 Fahrenheit (F), heart rate (HR) 75, blood pressure (BP) 109/49, respiratory rate (RR) 16, and peripheral capillary oxygen saturation (SpO2) of 99% on room air. Initial examination documented the patient as alert, soft abdomen, with generalized abdominal tenderness as well as rebound tenderness. Initial serology revealed a white blood cell (WBC) count of 19.8, hemoglobin (Hgb) 12.4, platelets (Plt) 262, sodium (Na) 138, potassium (K) 4.7, blood urea nitrogen (BUN) 18, creatinine (Cr) 0.79, carbon dioxide (CO2) 26, glucose (Glu) 146, total bilirubin (Tbil) 0.6. Lactate 1.6. Procalcitonin 0.3. Urinalysis with pyuria and bacteriuria. Computed tomography (CT) of the abdomen/pelvis was performed which noted an enlarged liver and spleen, doubtful appendicitis, moderate bilateral renal scarring and masses, and pelvic ascites. The patient was admitted to the hospital with an impression of sepsis, urinary tract infection, and possible diverticulitis. Temperature maximum (Tmax) was documented at 102.5F. Treatment plan included intravenous fluids, broad empiric antibiotic coverage, and symptom management. The following day the patient was documented to be improved without nausea or vomiting. Bilateral and suprapubic pain was still present. Vital signs found the patient to be afebrile and hemodynamically stable.  The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld in whole.

The inpatient stay was not medically necessary. Based on the clinical documentation provided, evidence based literature and standards of care, acute inpatient level of care was not indicated as medically necessary for the entire admission.
The patient presented with right lower quadrant pain and associated nausea. Initial evaluation was concerning for a leukocytosis, fever up to 102.5F, pyuria, and bacteriuria. A CT of the abdomen/pelvis was performed and did not reveal findings specific for an intra-abdominal pathological process. Treatment included intravenous fluids, anti-emetics, and empiric antibiotics. Multiple consultations were obtained who all had different impressions respectively. The infectious disease specialist had a final impression of pyelonephritis. Following observation care, the patient was documented as improved, afebrile, hemodynamically stable, tolerating oral intake, and leukocytosis had resolved. No other issues or complications requiring an inpatient level of care were documented.
Therefore, based on the clinical documentation provided, evidence based literature and standards of care, acute inpatient level of care was not indicated as medically necessary for the entire admission. The patient could have been managed at a lower level of care status.