Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Wound Pain
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an adult female. She presented to the emergency department having been transferred from an urgent care facility with the complaint of abdominal pain and inability to manage the existing surgical drain. She had undergone appendectomy 5 days earlier and was subsequently discharged from the hospital with a surgical drain in place. Her past medical history includes asthma, HIV (human immunodeficiency virus) infection, 
hypertension, and thyroid disease. At the time of emergency department presentation, she complained of abdominal pain and fever. The patient was tender in the left lower abdomen. The drain had serosanguinous fluid in the bulb. A computed tomography (CT) scan on the day prior to the emergency department presentation, showed pelvic fluid collection. It had been recommended that the patient stay in the hospital for assessment and treatment, but the patient eloped from the emergency department. The patient's vital signs on presentation showed a normal heart rate and elevated systolic blood pressure. Her temperature was normal. Her white blood cell count was normal at 7K (thousand). The patient was admitted to the hospital and started on intravenous antibiotics. An infectious disease consult was requested for her HIV (human immunodeficiency virus) status. On day #2, the patient reported improvement of the abdominal pain complaints. Vital signs were consistently normal during the period of monitoring. She was provided a diet. She was discharged from the hospital following a period of monitoring on day #3. Oral antibiotics were continued post-discharge. The surgical drain was removed prior to her discharge. The health plan denied coverage of the inpatient admission, noting in its letter that the patient underwent appendectomy and was sent to the emergency department from an urgent care center because of insufficient pain and need for drain management. The denial letter states that there was no documentation of need for an inpatient level of care. This letter references MCG (Milliman Care Guidelines) Pain Management, 26th edition. The denial is being appealed.

The inpatient admission was not medically necessary.

The medical records support that this patient could have been reasonably and safely monitored and treated at a lower level of care without need for full inpatient admission. This patient presented to the emergency department with abdominal pain. The evaluation with examination, lab data, and CT (computed tomography) scan did not indicate need for acute surgical intervention. The white blood cell counts, and vital signs were normal and stable. She was without fever. She was provided and tolerated a diet. On day #2 she reported improvement in her pain complaints. Pain medications were transitioned to oral medications. She was discharged from the hospital on day #3.
The patient was clinically stable at the time of presentation and remained so during the course of care. A lower level of care designation would have provided for surgical assessment, monitoring, and antibiotics. This lower level of care would have also allowed for overnight monitoring. The records reference MCG (Milliman Care Guidelines) as referenced in the health plan denial letter. These criteria state that inpatient management may be indicated if inpatient intravenous opioid treatment is required, pain is insufficiently responsive to non-opioid analgesia, alternative routes for opioid treatment are not appropriate or not sufficient, and intravenous opioid treatment is needed beyond observation care. In this case, the documentation does not support that these criteria were met to warrant an inpatient designation. A lower level of care would have appropriately provided for surgical assessment, monitoring, and provision of antibiotics and pain medications. Inpatient care was not required or medically necessary in this case per the referenced MCG (Milliman Care Guidelines) or generally accepted medical standards.