Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope

Treatment inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld

According to the patient's medical record, this is an adult female with a history of hypertension, sickle cell trait and colon cancer. She presented to the emergency room (ER) with complaints of abdominal pain, dizziness, syncope and a head injury. As per the ER provider note, the patient presented for diffuse abdominal pain. The patient stated she was walking out of the bathroom when she felt dizzy, and she passed out falling to the ground and hit her head. She denied fever or chills, vomiting or diarrhea. The symptoms were constant in duration and moderate in severity. Exam revealed injury to the left side of the head and generalized abdominal tenderness; she was alert and oriented to person, place, and time. She was afebrile with a blood pressure of 101/59 and pulse of 90. The assessment was and abdominal pain. Her white blood cell (WBC) count was elevated at 17,000 and the creatinine level was 1.8. A General Surgery consult was called and noted generalized abdominal tenderness. Surgery noted the computed tomography (CT) showing post-surgical changes from sigmoidectomy with right lower quadrant diverting loop ileostomy. A small parastomal hernia was noted containing non obstructed small bowel. Surgery noted no acute surgical intervention at this time. The patient was admitted. 

In addition, according to MCG (Milliman Care Guidelines) Inpatient and Surgical Care 25th Edition Abdominal Pain, Undiagnosed M-05 admission may be indicated for 1 or more of the following:  Hemodynamic instability; severe pain requiring acute inpatient management; peritoneal signs; identification of etiology or finding that requires inpatient care (e.g., aortic dissection, bowel perforation, bowel ischemia, ...; inability to maintain oral hydration (e.g. needs IV [intravenous] fluid support) that persists after emergency department and observation care treatment; suspected toxic megacolon; bacteremia; procedure that cannot be performed on ambulatory basis; ...The goal length of stay is ambulatory or 1 day. 

This patient did not have indications based upon these guidelines as well. In this case there was no indication for admission but rather observation as she was admitted for abdominal pain, and she did not have obstruction or any other pathology on the computed tomography (CT) scan; her ostomy was functioning, and she did not have nausea or vomiting. If anything, she had dehydration which improved with IV (intravenous) fluids. The patient did not have peritoneal signs and did not require to be kept nothing by mouth (NPO) because of inability to maintain hydration. She did not have any infection as cultures were negative and thus antibiotics were discontinued. 

Based upon the records provided, acute care services were not justified, and the patient could have been treated on an observation status. The patient did not have an acute issue that could not have been treated in an observation setting as she could have been hydrated without an acute admission. Her WBC normalized with hydration, and she did not have any sign of a surgical issue.  She did not have peritoneal signs and she did not have hemodynamic instability. She could have been treated with conservative management with fluids without inpatient care but rather observation. There was sufficient evidence to support the inpatient hospital admission was not considered medically necessary treatment for the patient's condition.

The health care plan did act reasonably, with sound clinical judgment, and in the best interest of the patient.

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical necessity is not substantiated.