Diagnosis: Enteritis and Urinary tract infection.
Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission. The denial is upheld.

This is a male patient with a history of alcoholic pancreatitis, who presented to the Emergency Department (ED) with abdominal pain. On presentation, the patient was afebrile, and his vital signs were stable. On examination, there was no abdominal rebound or guarding. Laboratory findings revealed that there was no leukocytosis. The patient's hemoglobin was elevated, but his renal function was normal. The patient's computed tomography (CT) scan revealed enteritis. The patient was treated with intravenous (IV) hydration and antibiotics. The patient also received antibiotics that would cover a urinary tract infection (UTI).

Clinical indications for admission for Gastroenteritis (M-170) include having a suspected severe infection, such as bloody diarrhea, peritoneal signs, hemodynamic instability, severe vomiting, severe dehydration, and a persistent severe electrolyte abnormality. In this case, the patient did not have these conditions.

Based on the review of the medical record and literature, the inpatient hospital admission was not medically necessary for this patient. This patient had enteritis. However, intravenous (IV) hydration could have been given in the Emergency Room (ER) with observation status. The patient's enteritis and urinary tract infection (UTI) could have then been treated with a course of oral antibiotics as an outpatient. The patient did not meet the Milliman Care Guidelines (MCG) criteria for an admission for enteritis.

The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital admission should be upheld. The medical necessity is not substantiated.