Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Dizziness
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is partially overturned.

This patient is a woman, She presented to the hospital with tachycardia in the setting of a complicated recent past medical and surgical history.  She had the established diagnosis of hypertension, hyperlipidemia, coronary artery disease, pre-diabetes, and cholecystitis with cholecysto-enteric fistula.  She was status post laparotomy with extraction of gallstones from the small bowel and subsequent placement of a cholecystostomy tube and endoscopic removal of intraluminal gallstones.  She also required endoscopic and angiographic embolization of a bleeding duodenal ulcer earlier in the year.

At the time of presentation the patient had a heart rate of 115 beats per minute.  She reported feeling dizzy and had shortness of breath.  The WBC (white blood cell) count was elevated at 12.67, sodium was low at 129 and potassium was elevated at 5.7.  The patient was admitted to the hospital.  She was seen in consultation by the acute care surgery service, the medical service, and dieticians.  She was treated with IV (intravenous) replacement of electrolytes.  On day two, the magnesium level was significantly low at 1.1.  She was receiving IV (intravenous) electrolyte replacement.

On day five, the patient still had poor oral intake, but she was without acute events and pain was well controlled.  Vital signs were normal on day five.  The existing abdominal drain was in place putting out seropurulent drainage.  The WBC (white blood cell) count had normalized to 10.6 K (thousand).

On day six, the patient's magnesium and sodium levels were still low at 1.2 and 135 respectively.  The social work service was working on placement post discharge back to Bedford Center.  The progress notes that correspond to the last three admission days document clinical stability with normal vital signs, normal magnesium and improving sodium.

The patient was considered to be stable for discharge to the extended care facility.

The health plan rationale for denial per the adverse determination letter is that the care and treatment provided could have been rendered with an observational level of care.

Yes, in part. The Inpatient admission was medically necessary, in part.
This patient underwent a series of complex abdominal interventions related to cholecystitis, cholecystoenteric fistula, gallstone obstruction of the small bowel, bleeding duodenal ulcer and need for percutaneous drainage of intra-abdominal fluid by interventional radiology.  She presented to the hospital with a heart rate of 115 beats per minute.  She reported feeling dizzy and had shortness of breath.  The WBC (white blood count) count was elevated at 12.67, sodium was low at 129 and potassium was elevated at 5.7.  This constellation of symptoms and lab abnormalities did warrant admission to the hospital, and given the patient's complex recent past medical and surgical history it was reasonable to anticipate a length of need for inpatient care to exceed 48-hours.

This patient had significant comorbid health conditions that required monitoring and treatment in addition to her acute lab and vital sign aberrations.  The intensity of service was not consistent with an observational level of care and support that an inpatient level of care was most consistent with the diagnosis and the treatment provided from day one thru day six.

The records support that the patient was clinically stable to transfer to the extended care facility for continued convalescence.  Inpatient care was not needed for the remaining three days of the admission, as the care provided on these days could have been rendered at the extended care facility.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient, in part.
An inpatient level of care was most appropriate in this case as supported by the submitted medical records.

Inpatient care was medically necessary for the remaining three days of admission because this patient had documentation of an acute vital sign and lab abnormalities in the setting of significant comorbid illness and complicated past medical and surgical history as is detailed above.

The patient required provision of appropriate nutritional support, replacement of electrolytes, and IV (intravenous) fluid supplementation in addition to monitoring and diagnostic evaluation for presenting complaints of dizziness and shortness of breath.  This care and treatment was most appropriately carried out in the inpatient setting as there was need for regular clinical assessment by the treating surgical service.  There was need for follow up lab assessment and monitoring of comorbid health conditions.

An observation level of care would not have been most appropriate for this patient whose care and treatment was reasonably anticipated to span a period of at least 2 nights.

However, the patient was clinically stable for transfer to a less intensive setting at the extended care facility.  The records do not document the continued need for inpatient care  for the remaining days of admission.