Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Low blood pressure, nausea and vomiting
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

This patient is an adult male with diabetes mellitus, hypertension, and alcohol dependence who presented to the emergency room after being found down by his wife. He endorsed progressive nausea / vomiting. He was treated with intravenous Zofran and intravenous fluids. The patient had a history of alcohol (EtOH) abuse and marijuana smoking. An ultrasound of the abdomen showed cholelithiasis with positive sonographic Murphy sign, 
raising concern for acute cholecystitis. Computed tomography (CT) of the abdomen with contrast revealed liver, spleen, and pancreas were unremarkable. Small gallstones were noted. 
There was no biliary ductal dilatation or adenopathy. A hepatobiliary iminodiacetic acid scan (HIDA) scan found no gallbladder activity identified at two hours consistent with cystic duct obstruction versus acute cholecystitis. Magnetic resonance cholangiopancreatogram (MRCP) revealed no cholelithiasis or gallbladder wall thickening and no pericholecystic fluid. However, 
there was small volume perihepatic and perisplenic ascites as well as mild peripancreatic edema and fat stranding, which may indicate acute pancreatitis. Surgery and Gastrointestinal were consulted. The patient was treated with full liquid diet, Protonix 40 milligrams (mg) intravenous piggyback (IVPB), Dilaudid 1 milligram (mg) intramuscular (IM) every 4 hours as needed (PRN), Zofran 4 milligrams intravenous push (IVP) every 6 hours as needed, Ceftriaxone 1 gram daily, and metronidazole 500 milligrams every 8 hour. For alcohol dependence, the patient was treated with Thiamine 100 milligrams intravenous push daily, multivitamin (MVT) daily by mouth (PO), Folic acid 1 milligrams by mouth daily, Ativan 2 milligrams intravenous push every 6 hours as needed for Clinical Institute Withdrawal Assessment (CIWA) over 10 and monitoring of Clinical Institute Withdrawal Assessment scale. On day #3, the patient reported right upper quadrant pain. A hepatobiliary iminodiacetic acid scan (HIDA) scan was ordered. The patient remained nothing by mouth (NPO). On day #4, the patient reported right upper quadrant pain without fevers or nausea / vomiting. Full liquid diet was started.

The proposed treatment was medically necessary.

The patient required an inpatient level of care due to prolonged nothing by mouth (NPO) status, workup of right upper quadrant pain, administration of intravenous antibiotics, and management of alcohol dependence. The medical records do support that the acute inpatient admission was medically necessary. The patient did require services of such intensity that could have been safely and effectively provided only on an inpatient level of service. The health, safety, and medical condition of the patient would have been threatened by providing the care given in a lower level of care setting. Therefore, based on review of the submitted medical records, the requested inpatient level of care was medically necessary for the dates of service in question as it required the intensity the level of care necessary to provide safe, adequate and effective treatment for this patient's condition.