Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital stay. 
The denial is upheld in whole.

The patient is a male with a history of peptic ulcer disease, hepatitis C, tobacco use, and opiate disorder, who presented to the hospital with abdominal pain, hematemesis, and dark stools. The patient has a history of right upper quadrant colicky pain for several years. Recent right upper quadrant ultrasound and computed tomography (CT) scan of the abdomen and pelvis demonstrated hepatic steatosis. The abdominal pain persisted after discharge, and 3 days before arrival, was associated with nausea and retching. He reported a small volume of dark red emesis, a nonproductive cough for several months, and weight loss. The last episode of emesis was on the day of admission.

The patient was admitted to the hospital due to small volume hematemesis worrisome for Mallory-Weiss tear from retching. Gastroenterology was consulted to evaluate the patient the following morning. Intravenous (IV) fluids were started, and the patient was given proton pump inhibitor (PPI) IV twice daily. A repeat ultrasound was ordered to evaluate the presence of hydronephrosis seen on the previous scan and whether it was contributing to the pain. Chronic pain medications were continued. The medical attending, who evaluated the patient, also expressed some concern for unreported alcohol use. They also ordered human immunodeficiency virus (HIV) testing and sputum induction for acid fast bacilli (AFB) smear, as the chest x-ray showed a right lower lobe infiltrate.

The patient remained hemodynamically stable. The AFB smears were negative. The CT scan of the chest was done, showing calcified granulomas without any active disease. Therefore, TB work-up was unrevealing, and the patient was removed from isolation. He had no recurrence of gastrointestinal (GI) bleeding. He was deemed stable for outpatient follow-up and discharged home.

The subject under review is the medical necessity for the inpatient level of care.

The health plan's determination is upheld in whole.

The primary concern for this patient coming into the hospital was the possibility of a GI bleed. The patient was hemodynamically stable, with stable serial hemoglobins. The patient did not require endoscopic evaluation and intervention from actively bleeding ulcer, varices. There was no evidence of acute pathology of the GI tract.
The medical team's subsequent concern was for the possibility of tuberculosis given the weight loss, and chest x-ray infiltrates. Typical diagnosis of tuberculosis rule out can be accomplished under a lower level of care status. The patient was not hypoxemic or hemodynamically unstable. The patient did not originate from an endemic area, and the only possible high-risk factor was under-reported alcohol use. There was no evidence of concurrent HIV infection. Once the patient ruled out with serial sputums, he was stable. This is a typical presentation for rule out TB that can be completed at a lower level of care status. There was no clear indication for admitting this patient to the inpatient stay, as there was no evidence of respiratory distress, impending respiratory failure, suspicion for high infectivity, or hospitalization mandated by a public health authority.