Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal-Abdominal/Stomach Pain.
Treatment: Inpatient Hospital stay.

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

The patient is a male with a history of diabetes mellitus, hyperlipidemia, fatty liver disease, and B-cell acute lymphocytic leukemia (ALL), on CALGB10403, Rituximab, and Peg-Asparaginase. He presented to the hospital with severe abdominal pain and nausea. He had a similar episode last month. The patient was currently taking Mercaptopurine (6-MP). A day before presentation, he was given supportive care and platelets for a platelet (Plt) count of 23,000. He also received intravenous (IV) fluids and pain medications. On presentation, he was hemodynamically stable. His exam showed significant abdominal tenderness. The patient also had guarding, per report. A computed tomography (CT) scan of the abdomen and pelvis showed wall thickening withing the segment of proximal ascending colon measuring approximately 8 centimeters (cm). There was a concern for infection or inflammation. His labs showed a white blood cell count (WBC) of 1.7, a hemoglobin of 9.6, a Plt count of 68,000, a total bilirubin (T.Bili) of 1.6, an aspartate aminotransferase (AST) of 84, and an alanine aminotransferase (ALT) of 167. The patient was started on IV hydration, IV Unasyn, IV Reglan, and Zofran. His chemotherapy was held. He continued fluconazole, Acyclovir and Unasyn. His Bactrim was held. His Unasyn was changed to Zosyn. Stool cultures and Clostridium difficile (C. diff) testing was sent. The C. diff was negative. Eventually his stool studies were negative for any bacterial infection but was positive for norovirus. His antibiotics were stopped, and he was continued on supportive care. The patient's transaminitis worsened with an AST and ALT of 154 and 307. His fluconazole and Acyclovir were held temporarily. He was subsequently discharged on oral Levaquin.
At issue is the medical necessity of the inpatient admission.

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

The patient met the admission criteria for several reasons. The patient had symptoms that were attempted to be managed in the outpatient settings. However, his symptoms persisted. Per Milliman Care Guidelines (MCG) Health Inpatient & Surgical care 25th edition Gastroenteritis ORG: M-170 (ISC), for the patient who has severe abdominal pain, peritoneal signs (guarding), and dehydration (failed outpatient therapy), the inpatient admission is indicated [1]. Moreover, he was neutropenic and in the setting of inflammatory changes, abdominal pain, and ongoing chemotherapy, he was at risk of typhlitis. Typhlitis is a clinical diagnosis, but it can be a hematological emergency and can be life threatening. Therefore, antibiotics until clinical stability were warranted [2]. Finally, the patients on CALGB10403 have a 24% to 25% risk of febrile neutropenia and infection that can increase the risk of mortality and morbidity. Moreover, the older patients receiving this regimen can have even greater risk of infection and febrile neutropenia [3]. Therefore, it was completely reasonable to keep the patient in the hospital during treatment while the patient had active symptoms and concern for infection/inflammation while the patient was neutropenic.