Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Intractable left flank pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial was upheld.

This patient is a male with a past medical history of hypertension, coronary artery disease, hyperlipidemia, a percutaneous transluminal coronary angioplasty (PTCA), and prediabetes.  The patient presented to the Emergency Department with subjective complaints of severe left-sided flank pain for two months.  The patient described the pain as an inside pain that was non-tender and was radiating to the groin.  The patient had previously gone to an Emergency Room for the same complaint where he underwent a CT scan that the patient indicated showed nothing. A CT scan revealed multiple findings including a 7 mm nodule in the lung base and hypertrophy of the left adrenal gland with a recommendation for magnetic resonance imaging (MRI).  The patient had a slightly enlarged prostate gland.  There was a complete loss of bone density in the anterior aspect of L2.  There was no aneurysm.  The patient had smoked 10 cigarettes/day for 50 years.  The CT scan of the abdomen and pelvis revealed an L2 lytic mass with soft tissue Gleason lesion and bilateral lung nodules.  The patient was admitted for intractable left flank pain for two months with concerning findings of metastatic disease on a CT scan of the abdomen and pelvis.  The patient underwent a fine-needle aspiration of the vertebral body that was positive for malignant cells.  The pathology report results revealed that the patient had metastatic carcinoma. Pain medications were given. The patient was followed by Oncology and was stabilized and discharged.

This request was previously denied as the patient had left flank pain radiating to the groin for two months.  Based on the tests and services the patient received, the insurer determined that the patient did not need to be admitted to the hospital.  The mass on imaging could have been evaluated as an outpatient.  At most, it was noted that the patient needed observation to titrate his pain medication and observe for any acute changes or worsening in his condition.

MCG indicate that admission for abdominal pain would be appropriate for patients who have peritoneal signs and symptoms, such as severe abdominal tenderness; when an evaluation requires the patient not to eat or drink anything for an extended period of time; or for the necessity of identification of etiology or finding that requires inpatient care.  Additionally, observation care would be appropriate for a patient with a suspected condition requiring continued monitoring or for a patient with undiagnosed pain after evaluation and initial treatment with concerning findings on examination or diagnostic testing.  

The patient underwent diagnostic testing initially which revealed a mass.  The patient had pain for two months.  The pain was noted to be 10/10.  The patient underwent a fine-needle aspiration and diagnostic studies, which could have been performed on an outpatient basis or on an observation status.  Therefore, the healthcare plan acted reasonably, and with sound medical judgment, and in the best interest of the patient.  The inpatient admission is not considered medically necessary for this patient.

Based on the above, the medical necessity for the inpatient admission is not substantiated.  The insurer's denial is upheld.