Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia; vision loss
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult female with anemia for whom coverage of an Inpatient Hospital Admission for 47 days is the subject of review. Coverage was previously denied per Milliman Care Guidelines as the patient was not identified as having unstable vital signs that did not improve, active ongoing bleeding or blood breakdown that could not be controlled, abnormal mental status (coma, confusion) that was severe or persistent, significant symptoms that did not respond to treatment with blood transfusion and observation care, severe dangerous abnormal heart rhythms or new kidney failure. Rather, the medical records reviewed revealed that the patient had vision loss left eye greater than right eye (OS>OD) and was homeless. Discharge was delayed because it was felt that the patient's visual problems would prevent her from being accepted at a shelter. The patient's low blood count was treated and responded to blood transfusion within the observation period of hospitalization which was approved. Upon appeal, the hospital notes Federal Regulations that prevent a hospital from discharging a patient until services required in the Discharge Plan are secured. The patient was characterized as not "a safe discharge to the street and would not be accepted at any shelter due to her inability to care for herself due to vision loss." The patient was refusing indicated care (cataract surgery) and therefore the case was reviewed with Psychiatry, Risk, and Ethics for a formal capacity assessment to comment on next steps. At the time of the patient's admission, the patient complained of blurry vision which had been present for years but had become severe in the past 3 weeks. She was only able to see vague shapes from her left eye. An ophthalmologic exam found bilateral blepharitis, poor ocular surface, and shallow appearing anterior chambers with bilateral white cataracts. Vision was found to be light perception right eye (OD) and counting fingers at 6 inches without improvement on pinhole testing. On day #4, inpatient cataract surgery was offered but the patient refused. She preferred to work with a social worker to have somewhere to go after surgery with plans made for outpatient surgery later. On day #18, the patient was reported as agreeable to cataract surgery tentatively scheduled however, at a preoperative evaluation, the patient again refused to sign consent forms and wanted to be discharged to a shelter and return for outpatient surgery. On day #38 the patient was judged to have the capacity to consent. On day #39, it was noted that there was an opportunity to have surgery performed with family willing to be present and supportive. The family was not in agreement with the patient's plan to live in their family home in Louisiana, and that she continued to refuse placement locally. On day #47, the patient was deemed medically stable for discharge.

The requested health service was not medically necessary.

This patient was identified as having mature cataracts limiting vision in the best eye to counting fingers. Cataract surgery is routinely performed on an outpatient basis. That this patient refused to undergo cataract surgery does not establish medical necessity of an inpatient level of care. There is no documentation of hemodynamic instability or uncontrolled pain. The patient's anemia could have been managed at an observational level of care. Inpatient hospital admission was not medical necessary in that it was not the level of care necessary to prevent, diagnose, manage, or treat conditions in the person that cause acute suffering, endanger life, result in illness or infirmity, interfere with such person's capacity for normal activity, or threaten some significant handicap.