Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male with a past medical history significant for hypertension, chronic kidney disease, diabetes mellitus with neuropathy, asthma, gastroesophageal reflux disease (GERD), benign prostatic hyperplasia (BPH), hyperlipidemia, and anxiety who presented to the emergency department with a several-day history of epigastric abdominal pain that radiated down to the hypogastric region. There was cramping, associated with nausea. The patient also reported brown stool with black spots. He denied hematochezia or vomiting. Reportedly, he had similar episodes within the last year and was evaluated in several facilities. The patient stated that his kidney function deteriorated recently. For instance, his creatinine went from 1.5 to 2.95 within six months.

The patient was admitted to the hospital with a diagnosis of intractable abdominal pain and possible upper gastrointestinal (GI) bleed, also possible peptic ulcer disease. In the hospital, the patient was seen by a gastroenterologist. Esophagogastroduodenoscopy (EGD) was performed that demonstrated acute erosive gastritis. Biopsies were obtained. The patient also had esophageal candidiasis, which was treated with fluconazole. The patient was recommended to avoid non-steroidal anti-inflammatory drugs (NSAIDs).
During the hospital stay the patient was seen by a nephrologist. The nephrologist recommended Foley catheter placement since obstructive neuropathy was on the list of the differential diagnoses. The patient refused a Foley catheter and stated that he was going to see his own urologist as an outpatient after discharge.
Since the patient's clinical condition improved, and he tolerated his diet, he was discharged from the hospital.

The subject under review is the medical necessity for the inpatient stay. The health plan's determination is upheld.

The inpatient stay was not medically necessary for this patient.
It was mentioned that this patient possibly had gastrointestinal bleeding. This reviewer does not see evidence of that. The gastrointestinal bleeding was not confirmed by the endoscopic studies. The patient remained hemodynamically stable and did not develop significant acute blood loss anemia. The endoscopic studies showed no evidence of ongoing bleeding associated with high-risk endoscopic features. There was no evidence that the patient was hypotensive or had altered mental status.
The reason for his abdominal pain was likely related to erosive gastritis and esophageal candidiasis. At the same time, there was no evidence that the patient's abdominal pain was related to serious conditions such as acute cholangitis.
The review of the medical records did not reveal evidence of severe or persistent vomiting, severe or persistent dehydration, severe pain requiring acute inpatient management, signs of intestinal obstruction or peritonitis, bacteremia, or need for percutaneous or open drainage.
The patient's kidney function was abnormal. However, this patient had chronic kidney disease. The patient's kidney failure was not associated with significant electrolyte abnormalities.
Even though the patient's blood pressure was high at times, there was no evidence of hypertensive emergency, the condition that would necessitate admission at the acute inpatient level of care.
Overall, he remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. The patient could have been managed at a lower level of care status.