Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe abdominal pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned

This patient is a male who presented to the hospital with severe left-sided abdominal pain.  He had the established diagnosis of a chronic pancreatic pseudocyst complicated by intractable pain.  The patient had comorbid health conditions of seizure disorder and substance abuse. The patient underwent surgical treatment of the chronic pancreatic pseudocyst with laparotomy and cyst gastrostomy performed. The operative dictation details the specifics of this operation that included a 10 centimeter upper midline incision, opening of the anterior wall of the stomach, marsupialization of the posterior gastric wall to the chronic pancreatic pseudocyst, closure of the anterior gastrotomy, and abdominal wall closure.

On day two the patient reported pain despite provision of parenteral narcotic medication.  He was started on a liquid diet and monitored for signs of alcohol withdrawal.  On day three, vital signs were normal.  The diet was advanced to full liquids.  Lab data was monitored.  Pain medications were converted to oral medications and the patient was considered to be stable for discharge home.

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

Yes, the proposed acute inpatient admission was medically necessary.
This patient underwent a complex abdominal operation that involved a 10 centimeter upper midline incision, opening of the anterior wall of the stomach, marsupialization of the posterior gastric wall to the chronic pancreatic pseudocyst, closure of the anterior gastrotomy, and abdominal wall closure.  While this operation and the post-surgical care was provided without adverse event or complication, it was clinically reasonable to anticipate a length of stay of at least two nights.  Additionally, this patient had significant comorbid health conditions that required monitoring and treatment.  His diagnosis and comorbid health conditions did carry the potential for rapid clinical deterioration.  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.

An inpatient level of care was most appropriate in this case as supported by the submitted medical records. Inpatient care was medically necessary because this patient had documentation of a chronic pancreatic pseudocyst.  He underwent an open abdominal operation with gastrotomy and marsupialization of the pancreatic pseudocyst.  He required provision of appropriate post-surgical pain medications that was initially provided parenterally as the patient was restricted from oral intake.  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 two nights.