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201908-119898

2019

Healthfirst Inc.

Medicaid

Digestive System/ Gastrointestinal

Inpatient Hospital

Medical necessity

Upheld

Case Summary

The patient has prior history of prostate cancer treated with radiation and chemotherapy, 2 years prior to this presentation. The patient presented to the emergency department with a 3-week history of right upper quadrant pain with associated nausea and some vomiting as well as low-grade fevers. The patient was in Haiti, when the symptoms started, and reportedly was hospitalized there for 3 days, evaluated with an esophagogastroduodenoscopy (EGD), which showed reported inflammation and infection of the intestines. Reportedly, the patient was treated with Cipro and Flagyl. Upon discharge, the patient returned to the US, and came to the emergency department to be evaluated. The patient reported feeling nauseated, but had experienced no vomiting. The patient did not experience diarrhea. The pain in the right upper quadrant described as heaviness, persisted, but is relieved with applying direct pressure. The patient had a right upper quadrant ultrasound done in the emergency department which was negative. A computed tomography (CT) scan was also done, which showed no evidence of pancreatitis. The patient was admitted to the hospital, with concerns for an infectious etiology causing the right upper quadrant pain.

The health plan's determination is upheld. The inpatient stay was not medically necessary. According to the Milliman Care Guidelines (MCG) criteria for gastroenterology, gallbladder or bile duct inflammation or stone M-555, the patient does not meet criteria for inpatient admission. There is no evidence of acute cholecystitis, there is no evidence of acute cholangitis as the patient lacked objective fever, there is no documentation of elevated CRP greater than 10, or elevation in the white blood cell count. There is no radiologic evidence of common bile duct disease. There is no evidence of common bile obstruction, vomiting that is severe or persistent, there is no clinical evidence of dehydration with normal creatinine and electrolytes, there is no evidence of hemodynamic instability. The patient does not have bacteremia and did not require an interventional procedure to relieve his condition. As a result, a lower level of care is more appropriate.

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