
202001-124365
2020
United Healthcare Plan of New York
HMO
Digestive System/ Gastrointestinal
Inpatient Hospital
Medical necessity
Upheld
Case Summary
Diagnosis: Gastroenteritis
Treatment: Inpatient hospital services
The insurer denied coverage for inpatient hospital services. The denial is upheld.
This patient is a male who presented to the Emergency Department complaining of abdominal pain for several days. The patient detailed that he had a home-cooked meal that started the onset of abdominal pain. The patient stated that it was associated with emesis and diarrhea. He also stated that he had subjective fever and chills. He had no significant medical history. A physical exam revealed a temperature of 98.1°F with a blood pressure of 138/81. The patient's heart rate was 89 beats per minute (bpm) and the oxygen saturation was 96% on room air. The patient had clear and equal bilateral breath sounds with diffuse tenderness to palpation of the abdomen. There was no rebound and no guarding. It was recommended that the patient undergo laboratory and diagnostic studies. The laboratory studies revealed an anion gap of 5 with a white blood cell count of 13.7. A CT scan revealed findings consistent with pan-colitis, which was most pronounced in the ascending colon. The patient was admitted and was treated with intravenous (IV) medication to include ciprofloxacin, as well as Flagyl. He continued with treatment with no further significant adverse events. He was discharged the following day with instructions to follow-up given a period of medical stability.
According to current literature, a patient may be admitted to inpatient services when there is evidence of vomiting that is severe or persistent, dehydration that is severe or persistent, hemodynamic instability or there is suspected severe infection as evidenced by bloody diarrhea. Within the documentation, the above was not noted. The patient did not need an inpatient admission and could have been managed under observation status. He seemed to have developed gastroenteritis with no alarming signs. He had no comorbidities that made him high risk for mortality and morbidity. Observation with IV fluids and antibiotics is considered an appropriate course of action.
The insurer acted reasonably, with sound medical judgment, and in the patient's best interest.
The carrier's denial of coverage for the inpatient hospital services is upheld. The medical necessity is not substantiated.