Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Multiple Episodes of Diarrhea Following a Paracentesis. 
Treatment: Inpatient Stay. 

The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The patient is a female with a past medical history significant for chronic obstructive pulmonary disease (COPD), asthma, end-stage renal disease, diabetes mellitus, hypertension, congestive heart failure, and status post automatic implantable cardioverter defibrillator (AICD) who came to the hospital with multiple episodes of diarrhea after she had a paracentesis. The paracentesis was performed by interventional radiology on the day of admission and approximately 5.6 liters of fluid was taken out. When she was seen by the admitting physician, the patient denied headaches, visual disturbances, nausea, vomiting, dizziness, falls, chest pain, palpitations, lower extremity edema, fever, skin rash, recent travel, or sick contacts. 
On the physical examination, the patient was afebrile. Her heart rate was 76 beats per minute (bpm), her respiratory rate was18 breaths per minute, her blood pressure was 170/99 and her oxygen saturation was 95 percent (%) on room air. The patient was in no acute distress and was able to speak in full sentences. There were no signs of respiratory distress. The head, eyes, ears, neck, throat (HEENT) examination was within normal limits. The patient's neck was supple without lymphadenopathy, masses, jugular vein distention (JVD), and carotid bruits. Her lungs were clear to auscultation without wheezes, rales, or rhonchi. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. The abdomen was soft, non-tender to palpation, with normal bowel sounds, without guarding or rebound. The patient had normal peripheral pulses with no cyanosis or edema. The patient was awake, alert, and oriented times 3. The neurological exam was nonfocal. 

The laboratory evaluation revealed that the patient's sodium was 142, her potassium was 3.9, her chloride was 104, her bicarbonate was 24 and her blood urea nitrogen (BUN) was 62. Her creatinine was 10.2, her glucose was 78 and her liver function tests were unremarkable. The patient's white blood cell count was 5.73, her hemoglobin was 10.9, her hematocrit was 34.0, and her platelets were 223. The computed tomography (CT) scan of the head was interpreted as an unremarkable study. The patient had clear sinuses and mastoids. The patient was admitted to the hospital with diarrhea. 

In the hospital, the patient was seen by a gastroenterologist. The gastroenterologist recommended checking stool for culture, monitoring electrolytes, obtaining a CT scan of the abdomen and pelvis, and continuing treatment with Protonix. While in the hospital, the patient was seen by physical therapy (PT) and occupational therapy (OT) who recommended home physical therapy. 

The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient in its determination of medical necessity. 

The hospital stay was not medically necessary for this patient at the acute inpatient level of care. The patient's diarrhea was nonspecific and was not associated with any underlying severe medical conditions. There was no evidence that the patient had any underlying infection that manifested in bloody diarrhea. There was no evidence that the patient had severe abdominal pain or megacolon. There were no peritoneal signs on the exam. There was no mention that the patient had a toxic megacolon, hemodynamic instability, severe or persistent vomiting, or severe or persistent dehydration. Taking into consideration these facts, an alternate level of care was most appropriate. 

Overall, this patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.