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 male with past medical history (PMH) of increasing marijuana consumption, and hemorrhoids, who was sent from another provider after presenting with complaints of worsening blood in stool and right sided abdominal pain.  His bloody stools started one year ago; however, the patient did not seek medical attention due to COVID and not having medical insurance. The patient says his abdominal pain is worse with movement and inspiration, it radiates to his right shoulder and he has had about 15 pounds weight loss. 

The patient was hemodynamically stable on arrival to the emergency room.  He was not hypoxic and was not bleeding.  His computed tomography (CT) scan showed an annular mass involving the rectum extending over a length of approximately 5.5 centimeters consistent with septal neoplasm; presacral lymph nodes measuring up to 1.3 by 1.2 centimeters suspicious for metastatic nodal disease; hepatomegaly with extensive bilobar hepatic metastatic disease; mild intrahepatic biliary ductal dilatation with normal caliber common bile duct (CBD). The patient was admitted for further workup.  He had stable labs and underwent colonoscopy which demonstrated the mass.  He was then discharged with outpatient follow up.

No, the proposed inpatient admission was not medically necessary.
The patient was hemodynamically stable.  As this patient had a condition that could reasonably be expected to be stabilized within 24 hours, observational status would be appropriate. This patient could have been managed in a lower level of care such as observational status on the dates of service (DOS) in question.  As this patient was hemodynamically stable and could have been managed in a lower level of care, acute hospitalization was not medically necessary for the dates of service in question and the intensity of services was not necessary.  A colonoscopy with biopsy is performed on an outpatient basis routinely, and does not require acute level care for performance.  While this patient needed urgent work up, this could have been accomplished at a lower level of care. 

"Generally a person is considered to be in inpatient status if officially admitted as an inpatient with the expectation that he or she will remain at least overnight. The severity of the patient's illness and the intensity of services to be provided should justify the need for an acute level of care. An inpatient admission solely because the patient has been kept in observation status over 23 hours would not be considered medically necessary." (American Health Information Management Association).

"Observation was meant to be a short period of time for providers to assess whether patients required admission for inpatient care, or could be discharged. Typically, this was meant to last fewer than 24 hours and only rarely spanned more than 48 hours." (Society of Hospital Medicine).

"In summary, hospital case managers are a crucial resource for making admission decisions. Hospitalists should be familiar with Medicare criteria for inpatient versus observation status. Patients who are likely to require 24 hours or less for a disposition decision should be assigned observation status. When in doubt, admit to observation since conversion to inpatient status is a simple process." (Pinson, R.).