Diagnosis: Urinary Retention.
Treatment: Inpatient Hospital Admission.

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

This is a patient with history of multiple ventral hernias, status post a mesh repair complicated by a fungal infection, who presented to the emergency department with complaint of abdominal pain, nausea and difficulty urinating. The patient had undergone an uncomplicated hernia repair 2 weeks prior but required a foley catheter on discharge for urinary retention. Foley was removed at an office visit but required replacement. The patient did not have foley in the emergency department visit. Computed tomography scan revealed free air in abdominal area. Serum white blood cell count was high; urinalysis (U/A) was abnormal. The patient was started on intravenous antibiotics, and was transferred to a surgical unit in anticipation of possible surgical intervention. Foley was placed with Urology service assistance, 600 milliliters (ml) of urine obtained. Urology/Infectious diseases consulted. The patient's white blood cell count decreased and he remained asymptomatic. Culture returned negative for growth. The patient was cleared for hospital discharge with a foley in place, outpatient follow up care was arranged.

Per Milliman Care Guidelines (MCG) Abdominal Pain, Undiagnosed - patient fails to meet clinical indications for admission. The patient also fails to meet indications for admission under MCG Urologic Disease "Acute urine retention requiring inpatient care" and MCG Urinary Tract Infection (UTI).

The health care plan acted reasonably and with sound medical judgement and in the best interest of the patient. The inpatient admission was not considered medically necessary for this patient.

The insurer's denial of coverage for the inpatient hospital is upheld. Medical Necessity is not substantiated.