Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain; Renal Mass
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The health plan's determination is upheld.

The patient is a female who was admitted on with abdominal pain. She had a 5-day history of abdominal pain with distention and diarrhea. She felt bloated but denied any fevers or chills. The evaluation in the emergency department (ED) with a computed tomography (CT) scan revealed a right renal mass, worrisome for cancer. There was evidence of necrosis within the mass, with extensive ascites and peritoneal carcinomatosis. The patient was admitted to the hospital with a urology consultation.
Her vital signs appeared stable. An examination of the abdomen revealed distention, but it was otherwise normal. The medical team consulted interventional radiology for a biopsy of the renal mass.

The urologist assessed the patient on the day of admission and requested tumor markers, a CT of the chest to evaluate for distant disease, and a magnetic resonance imaging (MRI) of the abdomen. They suspected the patient might have two primary malignancies, renal cell carcinoma and a secondary metastatic malignancy of an unknown primary site. A paracentesis was also requested from interventional radiology, with fluid cytology and omental biopsy.

The laboratory studies were fairly stable, including electrolytes and renal function. The patient's white blood cell count was mildly elevated to 12.9. Hematology also evaluated the patient and agreed with the assessment. The patient's abdominal pain resolved, and she was able to tolerate food and liquid. As a result, she was discharged home the day after admission with instructions to have the biopsy performed by interventional radiology the day following her discharge, and then to follow up with the appropriate specialists in the outpatient setting while awaiting the test results.

In its determination of medical necessity, the health plan acted reasonably, with sound medical judgment, and in the patient's best interest. An inpatient hospitalization is not warranted in this case.

The requested health service/treatment of an inpatient hospital admission was not medically necessary. The patient presented to the hospital for abdominal pain and was incidentally found to have a right renal mass and omental carcinomatosis and ascites. Within 24 hours of hospitalization, the patient's abdominal pain resolved, and she tolerated the diet. The documentation does not reveal a persistent inability to eat or drink, which would require ongoing monitoring and treatment. There was no evidence of bowel obstruction as a result of the carcinomatosis. There was no evidence of hemodynamic instability. The patient's renal function was unaffected by the kidney mass. There was no evidence of ureteral obstruction or hydronephrosis. Evaluation and treatment of malignancies are typically completed in an outpatient setting. It was reasonable and expected that the patient's diagnosis and staging could be completed in an ambulatory setting, with biopsy, imaging, and lab work, along the continuum of care.

An inpatient level of care is indicated for acutely ill patients who do not rapidly improve and require ongoing monitoring. This patient's evaluation and treatment do not satisfy those criteria. An alternate level of care is appropriate for evaluating this patient's abdominal pain. An appropriate discharge plan was established to diagnose and treat the suspected malignancy.