Appeal type: Medical necessity
Decision: Overturned


Diagnosis: Pancolitis

Treatment: Inpatient admission

The insurer is denied coverage for inpatient admission.
The denial is reversed. 

This case involves then a male who presented to the Emergency Department (ED) with complaints of severe stomach pain and nausea and the inability to feel his hands. The patient stated that he had vomiting and diarrhea as well. The patient stated that he had 12 bowel movements and vomited countless times since his symptoms started. The patient's past medical history included hypertension as well as focal segmental glomerulosclerosis (FSGS) kidney disease. The patient's vitals were: temperature of 98.9, heart rate of 102 bpm, blood pressure of 169/109, and an oxygen saturation of 100% on room air. On exam, the patient was alert and oriented, and had clear, bilateral breath sounds on auscultation; there was tenderness to the right upper quadrant as well as left lower quadrant of the abdomen.  The patient's laboratory studies showed: BUN of 26, creatinine of 3.8, albumin of 1.7, white blood cell (WBC) count of 27.08, hemoglobin of 9.9 and hematocrit of 29.2. The patient had a negative C. difficile and the physician indicated the patient should undergo diagnostic studies.  The patient's computed tomography (CT) scan of the abdomen/pelvis showed pancolitis and a collapsed stomach with mildly thick-walled surrounding infiltration raising suspicion for gastritis; there was also hepatomegaly. 

It was recommended that the patient be admitted for further evaluation. In the ED, the patient received morphine as well as Zofran and intravenous (IV) fluids. The patient underwent multiple consults and the patient reported two watery bowel movements; his pain had resolved, and his leukocytosis had improved. It was recommended the patient undergo gastrointestinal (GI) evaluation for inflammatory bowel disease (IBD) work-up. The patient was also recommended to receive probiotics. The patient's renal follow-up on indicated that the patient felt okay. The patient indicated that he was not eating much, and it was recommended that the patient undergo additional studies. It was recommended that they add more potassium and IV fluids. The patient continued with treatment and on the patient had complaints of diarrhea and abdominal pain overnight. The documentation indicated that the patient was having swelling due to discontinuing diuretic use. The patient was tolerating clear liquids and had reports of occasional nausea but no vomiting.  The patient did not have any new complaints. The patient continued with treatment and there was no documented acute event overnight. The patient indicated that he had difficulty sleeping due to pain however, was moderately relieved with medication. The patient continued to tolerate clear liquids and was recommended to undergo an esophagogastroduodenoscopy (EGD) for gastritis. 

Based on the review of the medical records, the patient was severely immunocompromised and presented with acute abdomen. The patient's clinical workup in the Emergency Department showed that this patient was febrile in the setting of severe pancolitis noted on imaging. The patient had focal segmental glomerulosclerosis (FSGS) kidney disease, and his renal insufficiency was worse from his baseline. The patient had significant leukocytosis of 27.08. Literature review supports that this patient was at risk for high mortality and could not have been managed in Emergency Department or under observation. Given this patient's comorbidities and immunocompromised status, this patient was unable to use certain medications. Thus, inpatient admission was medically necessary to treat this patient's complex, clinical presentation.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient admission should be reversed. The medical necessity is substantiated.