Diagnosis: Anemia of Malignancy, Acute kidney injury (AKI)

Treatment hospital admission

The insurer denied coverage for hospital admission

The denial is upheld

This is a male with known metastatic prostate cancer, to multiple sites, atrial fibrillation, chronic kidney disease (CKD), who fell at the infusion center. The patient was sent to the emergency room (ER). In the ER his vital signs were stable. His creatinine was 2.67 (up from baseline), and electrolytes were otherwise normal. A head computed tomography (CT) was negative. The patient was admitted to the hospital. Orthopedics was consulted the next day, and a magnetic resonance imaging (MRI) of the hip was obtained. He was given a transfusion and discharged home the following day.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. The hospital admission was not medically necessary for this patient. This patient could have been managed in a lower level of care, such as observational status, on the date of service (DOS) in question.

He would have been able to receive Amicar, transfusions, and monitoring of bleeding, in observational status. As this patient was hemodynamically stable and could have been managed in a lower level of care, acute hospitalization was not medically necessary for the date of service.

As this patient had a condition that could reasonably be expected to be stabilized within 24 hours, observational status would be appropriate.

"Generally a person is considered to be in inpatient status if officially admitted as an inpatient, with the expectation that he or she will remain at least overnight. The severity of the patient's illness, and the intensity of services to be provided should justify the need for an acute level of care. An inpatient admission, solely because the patient has been kept in observation status over 23 hours, would not be considered medically necessary." (American Health Information Management Association, 2018).

"Observation was meant to be a short period of time for providers to assess whether patients required admission for inpatient care, or could be discharged. Typically, this was meant to last fewer than 24 hours and only rarely spanned more than 48 hours." (Society of Hospital Medicine).

Based on the above, the medical necessity for the hospital admission is not substantiated. The insurer's denial is upheld.