Diagnosis: Abdominal pain, hematuria.
Treatment: Inpatient admission.

The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female patient who underwent an acute inpatient hospital admission. The patient has a history of hyperlipidemia, hypertension, chronic obstructive pulmonary disease (COPD) and a cerebral vascular accident (CVA). The patient had been brought in via ambulance with the complaints of worsening abdominal pain with hematuria. Increased heart rate and rate of breathing were reported as well as chills. An examination revealed tachycardia and left lower quadrant abdominal pain. A report of bloody diarrhea was noted by the general surgical consultant and pain in the left lower quadrant after eating. There was a concern for ischemic colitis.

The patient was admitted. Mild hypoxia on exertion was noted. The patient was empirically started on antibiotics. The patient was discharged on oral antibiotics once deemed stable.

No, the proposed inpatient admission was not medically necessary. The treatment as rendered was medically appropriate but not necessary at the level at which it was rendered.

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 one episode of rectal bleeding with abdominal pain, yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for a prolonged nothing by mouth (NPO) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission. As such the care in its entirety could have been rendered at a lesser level.

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