202110-142398
2021
United Healthcare Plan of New York
HMO
Cancer
Inpatient Hospital
Medical necessity
Upheld
Case Summary
Diagnosis: Rectal Cancer
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld.
The patient had rectal cancer and had a resection 3 weeks earlier. She had high ostomy outputs and was found to be dehydrated. She had a blood pressure of 79/52 and a pulse of 106. However, after IV (intravenous) hydration the blood pressure improved to 106/69 and the pulse was 90. There was no abdominal rebound or guarding. The blood urea nitrogen (BUN) was 36 and the creatinine 0.78. lmodium was ordered. She was able to tolerate a diet. She was given Bactrim for a urinary tract infection (UTI). The renal function improved.
Clinical indications for admission for Dehydration (MCG (Milliman Care Guidelines) M-123) include hemodynamic instability. This is defined as a vital sign abnormality that persists despite appropriate treatment. In this case, the blood pressure and pulse improved with the IV hydration. Other indications include severe vomiting, altered mental status, severe electrolyte abnormalities, and acute renal failure as manifested by a 3-fold increase in the serum creatinine. The patient did not have these conditions.
This patient developed dehydration from a high ostomy output. She required IV hydration and was also given imodium. She responded well to this treatment and her renal function improved. However, she was stable to have been given the IV hydration with observation status. She did not meet MCG criteria for admission for Dehydration. The health care plan acted reasonably and with sound medical judgement. An inpatient hospitalization was not medically necessary.
The health plan acted reasonably with sound medical judgment in the best interest of the patient.
The insurer's denial of coverage for the inpatient admission is upheld. Medical Necessity is not substantiated.