Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Polycythemia Vera
Treatment: Inpatient Hospital Stay
The health plan denied the requested inpatient hospital stay as not medically necessary.
The health plan's determination is upheld.

The patient is a female with a past medical history significant for type 2 diabetes mellitus, hypertension, hyperlipidemia, and polycythemia vera who presented to the hospital with complaints of abdominal pain. The pain was located in the left upper quadrant. The patient described the pain as stabbing and was exacerbated by movement and by taking a deep breath. The patient denied any bleeding, dizziness, falls, chest pain, palpitations, or gastrointestinal symptoms. It was mentioned that the patient was followed by a hematology/oncology specialist and was receiving treatment with Jakafi and Aspirin.

Upon initial evaluation in the emergency department, the patient underwent a computed tomography (CT) scan of the abdomen and pelvis that demonstrated worsening splenomegaly and a new splenic infarct.

When seen by the admitting physician, the patient's temperature was 99.7 (degrees) F (Fahrenheit). Her blood pressure was 149/79 millimeters of mercury (mmHg), with a pulse rate of 99 beats per minute (bpm), a respiratory rate of 15 breaths/min, and an oxygen saturation of 95% (percent) on room air.

The patient was resting in bed in no acute distress. She was awake, alert, and oriented x (times) 3. The head, eyes, ears, neck, throat (HEENT) exam was within normal limits. The neck was supple without lymphadenopathy, masses, jugular vein distention (JVD), or carotid bruits. Lungs were clear to auscultation without wheezes, rales, or rhonchi. The patient had a regular rate and rhythm, without murmurs, rubs, or gallops. The abdomen was soft with splenomegaly. There was abdominal tenderness in the left upper quadrant. There was no guarding or rebound.

The exam of the musculoskeletal system showed no gross deformities and a full range of motion in all 4 extremities. The skin was warm and dry. The rest of the physical exam was unremarkable. Laboratory evaluation revealed that the white blood cell count was 33.6, with a hemoglobin of 9.3, a hematocrit of 32.1, platelets of 111, a sodium of 136, a potassium of 3.7, a chloride of 99, a bicarbonate of 22, a blood urea nitrogen (BUN) of 11, and a creatinine of 0.96. The international normalized ratio (INR) was 1.02. Troponin was normal.

The patient was admitted to the hospital with polycythemia vera. She continued on Jakafi and Aspirin. Hypertension was well controlled at the time of admission. Due to the history of hyperlipidemia, the patient was continued on Simvastatin. An insulin sliding scale was initiated for the treatment of diabetes.

The patient was seen by a hematology/oncology service who recommended restarting treatment with Aspirin and continuing Jakafi. Flow cytometry and blood smear were sent. The abdominal pain was fairly well controlled with Percocet. After discussion with hematology/oncology service, the patient was discharged home in stable clinical condition with a recommendation for outpatient follow-up.

At issue is the medical necessity for the inpatient hospital stay.

I uphold, in whole, the health plan's determination of medical necessity.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.

This patient presented to the hospital with left upper quadrant abdominal pain that was related to a newly diagnosed splenic infarct. However, there was no evidence of hemodynamic instability or concomitant infection.

Admission at an alternate level of care to ensure hemodynamic stability and adequate pain control would have been the most appropriate, considering the clinical circumstances.