Diagnosis: Abdominal and pelvic pain.
Treatment: Inpatient admission.

The insurer denied the inpatient admission. The denial is overturned in part.

This woman presented to an outside hospital with abdominal and pelvic pain. Her recent history was notable for admission with bacteremia (S.agalactiae) that required treatment with Levaquin.

Workup showed occlusion of the inferior mesenteric artery, raising concern for bowel ischemia. Moreover, both echocardiogram and computed tomography (CT) showed possible dissection of the aortic root, raising concern for endocarditis. Additional imaging was recommended.

The patient was transferred to another facility. On arrival, she was stable but had suprapubic pain and nausea, symptoms that she attributed to being hungry. She was admitted for monitoring because of need to rule out endocarditis and/or aortic dissection. A repeat echocardiogram was suboptimal but showed no dissection at the aortic root. Ejection fraction and cardiac motion were normal. The patient was now asymptomatic with stable vital signs.

Yes, in part; the inpatient admission was medically necessary for admission day one. However, no, in part; the inpatient admission was not medically necessary for admission day two.

The patient presented with a clinical picture concerning for endocarditis complicated by embolization to the inferior mesenteric artery (IMA). She had a history of recent bacteremia and presented on this occasion with abdominal pain. Computed tomography (CT) showed inferior mesenteric artery (IMA) occlusion. Both computed tomography and echocardiogram raised concern for aortic root dissection. This picture can be explained by endocarditis and embolization to the inferior mesenteric artery (IMA). Even though the patient was stable when she presented to Montefiore, inpatient admission was warranted because of the legitimate concern for endocarditis complicated by embolization. This medical condition demands inpatient hospital stay because patients can rapidly deteriorate.

In contrast to the conclusion reached by the health plan, the admission day one was medically necessary. It is true that the patient was hemodynamically stable. However, she had history, symptoms and outside imaging concerning for endocarditis with embolization to the inferior mesenteric artery (IMA).

By admission day two, there was no longer concern for endocarditis with embolization to the inferior mesenteric artery (IMA). The health plan's conclusion that the patient did not need inpatient stay was reasonable for admission day two.