Appeal type: Medical necessity
Decision: Overturned

Diagnosis: RLQ pain; appendicitis/ileocecal inflammation 

Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was reversed.   

This is a male patient with a history of Bruton's agammaglobulinemia. The patient reported receiving IG therapy every 2-3 weeks for treatment. He was transferred from another medical facility after being worked up for complaints of right lower quadrant (RLQ) abdominal pain and diarrhea for several weeks. Prior to being transferred he had a computed tomography (CT) that revealed phlegmon in the RLQ with appendicitis/ileocecal inflammation. `He was consulted by General Surgery and evaluated for irritable bowel disease. On physical exam he was noted to have rebound tenderness in the right lower quadrant. He was consulted by Gastroenterology. A repeat CT was performed that showed circumferential thickening and mucosal hyper enhancement involving the base of the cecum as well as the terminal ileum and short segment of the distal ileum consistent with Crohn's disease. Steroids were recommended, however, gastroenterology recommended ruling out infectious colitis before implementing steroid therapy. The patient continued to complain of RLQ abdominal pain. It was recommended that the patient be transferred to another medical facility to continue medical treatment.  The patient was discharged with the understanding that family would transfer him directly to the other hospital. 

According to MCG Inpatient and Surgical Care 23rd Edition Abdominal Pain, Undiagnosed ORG: M-05 (ISC) admission may be indicated for 1 or more of the following: Surgery needed that cannot be performed on ambulatory basis; Peritoneal signs present;  Evaluation requires patient to not eat or drink for extended period (e.g., more than 24 hours; Hemodynamic instability;  Severe pain requiring acute inpatient management; Identification of etiology or finding that requires inpatient care (e.g., aortic dissection, free air, bowel ischemia, visceral organ torsion The goal length of stay is ambulatory or 1 day.

 In this case there was full indication for admission given the guidelines above as this patient could not have been treated in ambulatory/observation status. The patient has a condition known as Bruton's agammaglobulinemia which puts him at risk to infections and in this case, he needed to be treated in an inpatient setting and monitored given that it was not clear initially that this was infectious in origin versus IBD or appendicitis. The patient could not have been treated on an observation status as criteria for admission were met in contrast to what the insurer is stating. The patient did have peritoneal signs and rebound on exam and therefore could not have been treated on an observation status and discharged to home.  Also he has Bruton's agammaglobulinemia or X-linked agammaglobulinemia (XLA) which is a rare genetic disorder that affects the body's ability to fight infection.

Finally, MCG Inpatient and Surgical Care 23rd edition Inflammatory bowel disease ORG: M-565 (ISC) notes that admission is indicated for 1 or more of the following: hemodynamic instability; Acute severe ulcerative colitis ; severe signs or symptoms (e.g., bloody diarrhea, pain) insufficiently responsive to outpatient therapy (i.e., requires inpatient treatment such as IV immunosuppression); Abdominal abscess; Fistulizing Crohn disease; Toxic megacolon; Intestinal perforation; Signs of intestinal obstruction or peritonitisThis patient had signs of peritonitis and rebound on exam as well as having an immunodeficiency condition which put him at markedly increased risk to infection. He therefore needed to be treated in an inpatient setting and eventually by his immunologist.

The health care plan did not act reasonably and with sound medical judgment.  

Based on the above, the medical necessity for the acute inpatient hospital admission is substantiated. The insurer's denial is reversed.