Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bleeding in the stomach
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

The patient is a female. She had a past medical history significant for DM (diabetes mellitus), GERD (gastroesophageal reflux disease), urinary retention, and is a smoker. She presented to the ED (emergency department) after feeling dizzy and falling while walking to bathroom. She denied LOC (loss of consciousness). She has chronic diarrhea. She reported chills, myalgia, HA (headache), CP (chest pain) with cough, SOB (shortness of breath), nausea.

The patient's BP (blood pressure) was 174/98, then 155/101, with a heart rate of 96-106, SpO2 (pulse oximetry) 100% (percent) while on room air, and a temperature of 94.5. Her Emesis in the ER (emergency room) was dark coffee ground in color. The physical examination showed a soft abdomen and non-tender, ill appearing, abnormal breath sounds. The WBC (white blood count) was 11.78, Hgb (hemoglobin) 15.1, PT (prothrombin time) 10.9, INR (international normalized ratio) 0.93, PTT (partial thromboplastin time) 26.3, D-Dimer 6,125, Glucose 56, BUN (blood urea nitrogen) 21, Cr (creatinine) 0.46, Na (sodium) 140, K (potassium) 3.8, CO2 (carbon dioxide) 39, alkaline phosphatase 159, LD (lactate dehydrogenase) 965, Troponin (less than) <0.012, BPNPO (P-Natriuretic peptide) 86. CXR (chest x-ray) showed no acute findings. CTA (Computed Tomographic Angiography) shows no notable PE (pulmonary embolism) or clot burden (d-dimer possible lab error). Temperature confirmed rectally that the patient was mildly hypothermic.

The treatment tendered included BC (blood culture)x2, protonix, zofran, IV (intravenous) LR (lactated ringers), rocephin IVP (intravenous push), and Zithromax IV (intravenous).

The patient was then admitted. Per gastroenterology consult: CRP (C-reactive protein) ESR (erythrocyte sedimentation rate) are normal, TSH (thyroid stimulating hormone) low 0.238, trial lactose, would benefit from non-urgent outpatient EGD (esophagogastroduodenoscopy) and colonoscopy. The patient's emesis had resolved. She had new dysphagia intermittently to solids, lactose diet, and IVFs (intravenous fluids).

On day two, the patient's D-dimer was trending down to 689. Amlopdidoine was given for BP (blood pressure) 190/112. She had continued diarrhea, no emesis. Her K (potassium) was 3.6. IVFs (intravenous fluids) were continued.

On day three, the patient reports feeling better after IV (intravenous) hydration. She discontinued ceftriaxone and Azithromycin. Per the GI (gastroenterology) workup for diarrhea, the patient's BP (blood pressure) was 133/94, HR (heart rate) 18, and temperature 98.1. Her D-dimer normalized, and she was tolerating diet. As of day four, the patient was deemed stable for a discharge to home.

No, the Inpatient admission was not medically necessary.
The treatment rendered was medically appropriate, however, the level at which the care was rendered was not medically necessary as explained in detail below.

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.
Despite the patient's presentation the care as provided could have been rendered in its entirety at a lower level of care. The patient had an episode of dark emesis yet she did not undergo an endoscopy for risk stratification purposes. The patient also did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission. As such, the care could have been rendered at a lesser level.