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202110-143015

2021

Empire Healthchoice Assurance Inc.

Indemnity

Digestive System/ Gastrointestinal

Inpatient Hospital

Medical necessity

Overturned

Case Summary

Diagnosis: Digestive System/Gastrointestinal.
Treatment: Inpatient Hospital.
The insurer denied inpatient stay.
The denial is overturned in whole.

This patient is a male with a medical history of hypertension, collapsed right lower lung, diverticulitis, cholecystectomy, right knee meniscectomy, and right subdural hematoma. He presented to the hospital with complaints of left sided abdominal discomfort and bright red blood per rectum for 2 hours. His vital signs were a temperature of 97.9, pulse was 95, respiration rate was 18, blood pressure (BP) was 144/96 and pulse oximetry was 95% on room air. The physical examination showed absent breath sounds over the right lower lobe (RLL) and mild epigastric tenderness.
Abnormal laboratory values included a potassium at 3.4. The electrocardiogram (EKG) showed sinus rhythm with occasional premature ventricular contraction (PVC) and right bundle branch block (RBBB). The computed tomography (CT) scan of the abdomen showed active bleed per unofficial read. A colonoscopy showed non-bleeding internal hemorrhoids with diverticulosis and an 8-millimeter (mm) polyp in the sigmoid colon. His hemoglobin dropped from 14.4 to 11.7 and remained stable. The patient was discharged home.
At issue is the medical necessity of the inpatient stay.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of Inpatient Stay was medically necessary for this patient.
This patient had evidence of ongoing active bleeding. He presented to the hospital with an acute gastrointestinal (GI) bleed. There was no evidence of hemodynamic instability. There was, however, evidence of ongoing active bleeding with hemoglobin dropping from 14.4 to 11.7 as well as CT imaging showing extravasation of contrast in the descending colon. Based on current standards of care, the patient required frequent monitoring at the inpatient level of care, for continued active bleeding.
Therefore, the requested health service/treatment of Inpatient Stay was medically necessary.

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