Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pregnancy/Childbirth. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient hospital admission for medical necessity. 
The denial was upheld in whole. 

The patient is a female with a past medical history significant for sickle cell disease who was 14 weeks pregnant. She presented to the emergency department with complaints of lower abdominal pain as well as pain in her arms and legs. Her other symptoms included nausea and vomiting. The patient denied fever or chills. At the time of the initial evaluation, the patient was afebrile. Her blood pressure was 104/61, pulse rate was 78 beats per minute (bpm), respiratory rate was 18 breaths/min, and oxygen saturation was 100% on room air. Her lungs were clear to auscultation and her heart exam was unremarkable. The abdomen was soft and non-tender, without guarding or rebound tenderness. There was no pedal edema. 
Her laboratory evaluation revealed that she had a white blood cell count at 14.1, hemoglobin was 12.8, hematocrit was 37.2, and platelets were 193. Her serum sodium was 136, potassium was 5.5, chloride was 104, bicarbonate was 21, and glucose was 71. The total bilirubin was 1.2, alanine aminotransferase (ALT) was 22, aspartate aminotransferase (AST) was 42, and alkaline phosphatase was 55. The urinalysis demonstrated cloudy urine with a large number of white blood cells. 

The patient was admitted to the hospital with a diagnosis of sickle cell pain crisis, urinary tract infection, abdominal pain, and pregnancy. 
In the hospital, the patient was seen by the general surgery service. They were consulted for evaluation of abdominal pain, to rule out acute appendicitis. A magnetic resonance imaging (MRI) scan of the abdomen and pelvis was performed and showed no evidence of appendicitis. During the hospital stay, the patient received treatment with intravenous Ceftriaxone, which was administered for treatment of a urinary tract infection. 
Throughout the hospitalization, the patient's symptoms resolved, and she was transitioned to outpatient care. 
At issue is the inpatient stay for medical necessity. 

The health plan's determination of medical necessity is upheld in whole. 
The requested health service/treatment of inpatient stay was not medically necessary for this patient. 
 
Though this patient had a history of sickle cell disease, based on the review of the medical records there is no overwhelming evidence that the patient had the definitive clinical or laboratory signs of sickle cell pain crisis during this admission. This patient had unspecified abdominal pain as well as some nausea and vomiting, which are common symptoms in the first trimester of pregnancy. 

Based on the review of the medical records, there is no overwhelming evidence of a urinary tract infection. She had a small number of white blood cells in the urine, however, the nitrite in the urine was negative. The urinalysis demonstrated only a modest increase in the number of white blood cells, which in this case was 5-10/high powered field (HPF). There were no positive results of the urine culture. 

The patient underwent an MRI scan of the abdomen and pelvis that did not show evidence of acute appendicitis. The severity of the patient's condition and the complexity of the services provided did not rise to the inpatient level of care. Overall, the patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the inpatient level of care. 

Therefore, the inpatient stay was not medically necessary.