Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain, nausea, vomiting
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female. She presented by ambulance in the evening with a one week history of abdominal pain, nausea, vomiting and inability for oral intake. Abdominal pain had worsened on the day she presented. Her past medical history significant for pelvic inflammatory disease with previous drainage of hydrosalpinx and hypertension. The patient had recently been treated for a urinary tract infection as outpatient with oral antibiotics.

The patient's physical examination showed normal vital signs. The patient was afebrile. White blood cell count was elevated to 19,700 with left shift. Liver enzymes showed mild elevation. Serum lactate was mildly elevated to 2.9. Sepsis score was 1.9 at its highest at presentation but rapidly decreased. COVID (Coronavirus disease) testing was negative. Serum troponins showed no elevation. Urinalysis showed ketones but no evidence of infection. Ultrasound done @ 23:13 noted the patient was feeling better. No gallstones were visualized. A CT (computed tomography) scan done in the early hours  showed a fatty liver. The appendix was not visualized but there were no inflammatory changes in the area of the appendix.  Consults were ordered for Surgery and Gynecology.

Gynecology saw the patient in the ER (emergency room) and signed off on the basis that the patient's symptoms were not gynecological in nature. General Surgery (which was the admitting service) was consulted. Order to admit to inpatient was written. The patient was offered diagnostic laparoscopic but opted for medical management. The patient was treated with antibiotics and intravenous fluids. The patient improved over the day. Nursing notes note the abdomen was soft and non-tender. Clear liquid diet was ordered for the morning. Diet was advanced to regular on the evening. Repeat white blood cell count in the morning had normalized at 9,300 without left shift. The suspected etiology of the pain was a ruptured ovarian cyst. She was discharged.

The acute inpatient admission was denied by the Insurer as not medically necessary. The hospital has appealed the denial of the acute inpatient level of care. The appeal states on admission the patient was tachycardic (pulse of 98 beats per minute). The patient had leukocytosis, elevated liver enzymes (AST [aspartate aminotransferase]=40 / ALT [alanine aminotransferase]=49) and lactic acidosis (lactate=2.9 mmol/L [millimoles per liter]). The appeal states that the patient required "very close inpatient monitoring while slowly advancing diet, continuing intravenous fluid hydration and antibiotic therapy." The appeal states that this could not have been done in an outpatient setting.

No, the Inpatient admission was not medically necessary.

The patient rapidly improved with intravenous hydration and antibiotics. The patient was ordered for diet in the morning at the time of admission and advanced to regular diet that evening. White blood cell count returned rapidly to normal and sepsis risk rapidly improved. The patient was discharged the following day, little more than 24 hours after the admission order.

The care the patient received did not require acute inpatient level of care. The care the patient would have received at a lower level of care would have and could have been identical to that which she received. A lower level of care would not reasonably be expected to adversely affect the quality of care rendered or patient safety.

In response to the hospital's appeal that the patient required inpatient level of care, no reason is cited as to why the patient could not have been treated at a lower level of care, for example observation. The patient was not tachycardic. Liver enzymes were barely elevated. White blood cell count and elevated lactate were the only labs which warranted further workup/evaluation. However this workup and subsequent monitoring did not require inpatient care. In fact, at the time the order to admit, the patient was improving and labs had normalized that morning. The patient was ordered for clear liquid diet that morning and regular diet that afternoon. No reason is given why the care rendered could not have been at a lower level of care. Monitoring while advancing diet, administering intravenous fluids and antibiotics does not require inpatient level of care.