Dx: Digestive System/Gastrointestinal
Tx: Inpatient Hospital

Denied: Inpatient stay
Denial: UPHELD in whole

The patient is a female with history of severe constipation and hemorrhoids, who came into the emergency department because of rectal pain rated 10/10 and the inability to have a bowel movement. She was noted to have a white blood cell count of 11.2 with a left shift. The patient underwent an examination under anesthesia, hemorrhoidectomy, superficial lateral sphincterotomy, and fecal disimpaction. On post operative day 1 the patient was doing well and was discharged home. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld, in whole.

The patient had a clear need for a surgical procedure, but did not have a need for inpatient level of care from the hospital. There is no physician documentation of the need for an inpatient level of monitoring, complex diagnostics, or treatments other than the surgery. There is no evidence of patient specific problems that would require an inpatient level of care to meet medical needs or to assure patient safety. There is no evidence of a complicating event that occurred before, during, or after the patient's care that would require inpatient level of care.