Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain and Worsening Shortness of Breath
Treatment: Inpatient admission

The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male. He was admitted with right renal colic. He also had a cough, sputum production and shortness of breath.

The patient's vitals were as follows: Temperature 98.2, blood pressure 145/70, pulse 91, oxygen saturation 94%. The WBC (white blood cell) count was 7200. The creatinine was 0.9. CT (computed tomography) imaging demonstrated a small right renal calculus without hydronephrosis. He also had cirrhosis with a moderate right effusion and compression atelectasis of the right lung. IV (intravenous) pain medications, nausea medications, IV (intravenous) antibiotics and IVF (intravenous fluids) were administered.

On day two, the patient had no pain. IV (intravenous) pain medications, IV (intravenous) antibiotics, bronchodilators and IVF (intravenous fluids) were administered. He was treated for acute renal colic secondary to acute nephrolithiasis and acute urinary tract infection and acute COPD (chronic obstructive pulmonary disease) exacerbation with possible pneumonia. The urine culture grew 50-100,000 CFU/ml (colony forming units) Staphylococcus aureus.

On day three, the patient was discharged home. He was afebrile and hemodynamically stable throughout the stay.

No, the Inpatient admission was not medically necessary.
The patient's care could have been safely and effectively provided at an observation level of care. He was afebrile and hemodynamically stable throughout the stay.

The following criteria for an inpatient level of care were not met:

Inpatient admission required rather than observation care because of 1 or more of the following:
Significant finding or clinical condition judged too severe (eg, treatment intensity or expected duration requires inpatient admission) or too persistent (eg, insufficient improvement or worsening despite initial intervention or treatment for up to 24 hours) to be within scope of observation care, including 1 or more of the following:
1. Dyspnea that is severe or persistent
2. Other significant finding or clinical condition judged not to be within scope of observation care
3. Treatment or monitoring requiring inpatient admission (eg, due to intensity or expected duration) as indicated by need for 1 or more of the following:
4. Supplemental oxygen or respiratory treatments for over 24 hours that are performable only in acute inpatient setting
5. Chest tube placement with active evacuation (eg, suction, drainage)
6. Continuous intravenous infusion of anticoagulation, platelet inhibitor, vasoactive, or antiarrhythmic medication
7. Other treatment or monitoring requiring inpatient admission.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
An observation level of care was appropriate. The IVF (intravenous fluids) received could have been provided at an observation level of care, as the patient did not have evidence of severe dehydration.  Similarly, the antibiotics could have been provided at an observation level of care.