Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infectious Disease/Bacterial infection
Treatment: Inpatient hospital stay
The insurer denied the medical necessity of the inpatient stay
The denial is upheld in whole

The patient has a past medical history significant for asthma who presented with a 3-day history of severe gradually worsening epigastric abdominal pain that was associated with chest pain, back pain, myalgias, fatigue, weakness, dysuria, and low-grade fever. Also, the patient complained of chills and lightheadedness.
When the patient was seen in the emergency department, the temperature was 37.1F, blood pressure 125/73, respiratory rate 18 beats/min, pulse rate 106 beats per minute (bpm), oxygen saturation 97% on room air. The patient appeared to be a well-developed, well-nourished individual who was in no acute distress. The patient was awake, alert, oriented to person, and responsive and had a normal head, eyes, ears, neck, throat (HEENT) exam. The neck was supple without lymphadenopathy, masses, jugular vein distention (JVD), carotid bruits. The patient had a regular rate and rhythm, without murmurs, rubs, or gallops. Lungs were clear to auscultation without wheezing, rales, or rhonchi. The abdomen was soft, nontender to palpation, with normal bowel sounds, without guarding or rebound. The patient had tenderness to palpation over the right lumbar, sacral paraspinal region. The rest of the physical exam was unremarkable. White blood cell count was 14.3, hemoglobin 14.2, hematocrit 45.3, platelets 284.
The urinalysis revealed a trace of leukocyte esterase. The nitrite was negative. The rapid influenza test was negative. A chest x-ray demonstrated no acute cardiopulmonary process. Based on the evaluation performed in the emergency department, the patient was suspected to have sepsis and received treatment with intravenous antibiotics. The blood cultures remained negative. A computed tomography (CT) scan of the abdomen and pelvis demonstrated inflammatory changes in the perirectal fat suggestive of possible proctitis. During the hospital stay the patient was seen by a gastroenterologist who recommended treatment with intravenous antibiotics, laxatives, and a colonoscopy after clinical improvement.The patient was also seen by a neurologist because of the headaches.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
The review of the medical records clearly demonstrated that during the hospital stay the patient did not require any procedures or diagnostic studies necessitating admission at the acute inpatient level of care.
In addition, there was no evidence that the patient was unable to tolerate  meals or became severely dehydrated.
The patient was evaluated by a neurologist and GI specialist.
Based on the assessment, there was no evidence that the patient had an unstable medical condition that would justify admission at the acute inpatient level of care. The patient indeed had some lactic acidosis at the time of the initial evaluation. However, this condition resolved very quickly.
Taking into consideration all these facts, the admission at a lower level of care was reasonable, especially considering the fact that sepsis syndrome was suspected. It was important to monitor the patient closely for signs of hemodynamic instability and look for the source of infection.
Even though sepsis syndrome was suspected, there was no clear evidence of infection. There was minimal evidence that the patient had a urinary tract infection. There is no overwhelming evidence that either the severity of the patient's condition or the complexity of the services provided justified admission at the acute inpatient level of care.