202005-128241
2020
Healthfirst Inc.
Medicaid
Digestive System/ Gastrointestinal
Inpatient Hospital
Medical necessity
Upheld
Case Summary
Diagnosis: Abdominal pain with darkening stools
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.
The patient is a male who had presented to the facility in question with a report of two days of worsening abdominal pain with increasingly darkening stools. There was no non-steroidal anti-inflammatory drug (NSAID) use, tobacco or alcohol use. There was no hematemesis, nausea, emesis, dizziness, shortness of breath or fevers or chills. The patient had a history of a prior gastrointestinal (GI) bleeding with a duodenal ulceration. The patient was recently started on Xarelto. The patient had initially presented to his private physician with melena and hypotension with a systolic blood pressure in the 80s. The Xarelto was held. The presenting systolic blood pressure was 104. The presenting hemoglobin was 11.1. An esophagogastroduodenoscopy (EGD) showed a non-bleeding duodenal ulcer. The patient was noted to be clinically stable on presentation and the patient received supportive care with a discharge when deemed improved.
No, as explained in detail below, the proposed inpatient admission was not medically necessary.
Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had an upper GI bleeding event, yet he did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for a prolonged nothing by mouth (NPO) status, need for invasive surgery, need for invasive monitoring, need for a blood transfusion, severe electrolyte dyscrasias or any other indication for an acute admission. An endoscopy can be performed as an observation level patient or an outpatient. As such, the care could have been rendered at a lesser level.