Diagnosis: Rectal Bleeding
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male. He presented to the ED (emergency department) of the facility filing the appeal with gastrointestinal bleeding. The patient reported rectal bleeding, rectal pain, chills, nausea, and emesis for two days. The patient noted decreased oral intake and decreased urination. The patient also reported a dry cough and a headache.

The patient evidenced tachycardia on presentation and a temperature of 99.3. The patient had left lower quadrant pain on physical examination. A CT (computed tomography) scan showed thickening of the entire colon consistent with colitis. A GI
(gastroenterology) consultant recommended no antibiotics. However, as time passed and the situation changed, antibiotics were started and the patient was admitted for supportive care. Studies returned with Shigella noted. The patient signed out AMA (against medical advice).

No, the Inpatient admission was not medically necessary.
The care as provided was appropriate, but not medically necessary at the level at which it was provided.

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 infection; 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 NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring or treatments, need for blood products or a blood transfusion, severe
electrolyte dyscrasias or any other indication for an acute admission. As such, the care could have been rendered at a lesser level.