Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female who presented to the hospital emergency department (ED) with nausea, vomiting and abdominal pain secondary to an existing adjustable gastric band.  These symptoms had been worsening over the prior six-months.  Comorbid health conditions included sleep apnea and morbid obesity with an existing gastric band in place.  

At the time of presentation the patient was without fever and vital signs showed a normal heart rate.  The blood pressure was elevated at 160/106 millimeters of mercury (mmHg).  Computed tomography (CT) scan identified slippage of the lap band with partial obstruction of the stomach.  Serum electrolytes were normal.  The patient was treated with laparoscopic removal of the gastric band and upper endoscopy on admission day two.  The operative dictation and the anesthetic record describe an uncomplicated procedure.  The patient was treated with post-surgical monitoring, intravenous (IV) fluids, intravenous analgesia, and antiemetics.  The immediate post-surgical recovery was uncomplicated.  

On day three, following surgery, the patient had stable vital signs.  Her pain was controlled.  The diet was advanced.  The patient remained clinically stable and was discharged from the inpatient setting.

The health plan letter states that acute inpatient admission was not required in this case as the care provided could have been rendered with a lower level of care (observation).

No, the proposed inpatient admission was not medically necessary.
Acute inpatient admission was not required in this case as the care provided could have been rendered with a lower level of care (observation).  This lower level of care would have satisfied the clinical needs of this patient and would have provided for pre-surgical assessment, surgery on day two, and post-surgical monitoring including overnight observation until discharge on day three.

An inpatient level of care was not medically necessary in this case.  This patient is a female who presented to the hospital with obstructive symptoms related to a malpositioned lap band device.  She was clinically and hemodynamically stable at the time of presentation and underwent laparoscopic removal of the gastric band and upper endoscopy on day two.  There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care.  Additionally, there is no documentation of failure to achieve discharge criteria, conversion to open surgery, care for comorbidities, procedural complications, or any other condition requiring inpatient admission.  Acute inpatient care was not medically necessary for this patient as the care and treatment provided could have been rendered in the observational setting.  An observational level of care would have provided for presurgical assessment, perioperative care and monitoring, surgery on day two, provision of intravenous (IV) fluid and medication, and overnight care.

There is no compelling reason why this patient could not have safely and appropriately been treated at the observation level of care.  The patient underwent an uncomplicated surgical procedure.  There were no peri-operative complications or other clinical issues.  She remained stable and was discharged from the hospital on day three.  The patient was clinically stable following surgery as supported by the corresponding medical records.

Inpatient stay may be needed for failure to achieve discharge status criteria, conversion to open surgery, systemic infection, care for active comorbidities, or complications of procedure.  In this case, none of these indications existed to justify an inpatient level of care