Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An female enrollee has requested reimbursement for hospitalization services  and prospective authorization and coverage readmission to an acute care hospital to receive the following services: obstetrics and gynecology (ob/gyn) physician while inpatient; nephrologist, while inpatient; magnetic resonance imaging (MRI) scan of abdomen and pelvis, while inpatient, and colonoscopy while inpatient; double balloon endoscopy while inpatient, parasite testing while inpatient, and work up for definitive diagnosis while inpatient. Findings:  The physician reviewer found that the documentation provided fails to demonstrate the medical necessity for the services at issue. Inpatient care is medically necessary when the patients signs, symptoms, and general medical condition can only be managed safely in an acute inpatient setting, or when the patient requires diagnostic studies in an inpatient setting.  Inpatient care may also be medically necessary when the patient has to remain in an acute inpatient setting. Outpatient observation admission is appropriate when the provider is unsure about the patients need for inpatient admission and requires time for short-term treatment, assessment, and reassessment in order to make that decision or the provider anticipates that the patients condition can be evaluated/treated within 24 hours and/or rapid improvement of the patients condition can be anticipated within 24 hours. In this case, the patient was admitted in stable condition and could have been treated at a lower level of care.  At the time of admission, the patient was afebrile, with stable vital signs. Multiple diagnostic tests were negative for acute disease, including CT of the abdomen and pelvis, urinalysis, blood work and x-rays.  The patient was able to take oral nutrition and was voiding appropriately.  Accordingly, the care rendered at the inpatient level of care was not medically necessary. With regard for readmission into an acute care hospital and the request for multiple diagnostic screenings while inpatient, the documentation provided do not support the medical necessity for the requested services.  As noted above the patients vital signs were stable and multiple diagnostic tests were negative for disease. In this case, the patient is experiencing pain from a chronic condition.  Moreover, she has had an extensive outpatient work up that were also normal.  The records do not demonstrate the medical necessity to have these services provided at an inpatient level of care. Therefore, the request for inpatient care along with the request to be seen by an ob/gyn provider while inpatient; nephrologist, while inpatient; MRI scan of abdomen and pelvis, while inpatient, and colonoscopy while inpatient; double balloon endoscopy while inpatient, parasite testing while inpatient, and work up for definitive diagnosis while inpatient are not medically necessary.Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.