Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pleural Effusions
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient presented to the emergency room (ER) for abdominal pain and pleuritic chest pain following an emergency Cesarean (C) section for uterine rupture 6 days prior. The patient reported a fever of 101 degrees Fahrenheit (F) at home. Her vital signs were within normal limits. Lab results were remarkable for a hemoglobin (Hb) of 9.7, white blood cell count (WBC) of 10.1. The physical exam was remarkable for right lower quadrant (RLQ) pain. A computed tomography (CT) scan of the abdomen/ pelvis showed post-surgical changes to the anterior uterine wall, pneumonia in the bilateral lower lobes, and small bilateral pleural effusion. A transvaginal ultrasound showed echogenic debris in the endocervical canal. The patient was given doxycycline/ceftriaxone, fluids and morphine. She was admitted with an infectious work-up pending (cultures) and started on vancomycin/ Zosyn for hospital acquired pneumonia and potential intrabdominal infection along with fluid resuscitation. Gynecology evaluated her and based on the surgical procedure, did not believe there were retained products of conception remaining in the endocervical canal and to treat the patient for pneumonia. On hospital day 3, the antibiotics were de-escalated to Augmentin as the patient was feeling better. The vital signs remained within normal limits during the hospitalization. The patient was discharged home. At issue is the medical necessity of an inpatient stay.

An inpatient level of care was not medically necessary. The patient presented with right sided pleuritic chest pain and a cough. The vital signs were within normal limits. The patient was found to have pleural effusions and potentially pneumonia. Pleural effusions in the peripartum period are a common finding with an incidence of 25% of all women following delivery (Gourgoulianis et al 1995). The clinical significance of this finding is benign and these are not to be treated (Gourgoulianis et al 1997). Given that the patient was not hypoxic nor had any other vital sign abnormalities, she could have received oral antibiotics for pneumonia and her pleural effusion did not need an intervention. For her potential retained products of conception, these could have been a cause for her having some abdominal pain, although abdominal pain is common based on the surgical intervention she underwent 6 days prior. Evaluation by gynecology for retained products of conception is reasonable to occur within 2 midnights of admission and if retained products were present this would need intervention. If the patient needed further intervention, such as surgical intervention to remove the products, then the patient could have been switched from a lower level of care to inpatient. This was a low likelihood as patient had a white blood cell count (WBC) of 10.1 (low for infection in the abdomen/pelvis), no documented vaginal bleeding (lochia not documented), and the pain was not severe in the abdomen when palpated (Foreste et al 2021). Thus, the patient does not meet the Centers for Medicare and Medicaid Services (CMS) definition for the inpatient level of care as she was not expected to stay greater than (>) 2 midnights (CMS guidelines).