202202-146881
2022
United Healthcare Plan of New York
HMO
Digestive System/ Gastrointestinal
Inpatient Hospital
Medical necessity
Upheld
Case Summary
Diagnosis: Abdominal Pain.
Treatment: Inpatient Admission.
The insurer denied the inpatient admission.
The denial is upheld.
This patient is a male with a history of alcohol related cirrhosis, colon cancer status post resection and chemotherapy, and anemia of chronic disease who presented for ecchymosis over the abdomen. His alcohol level was 250, potassium was 3.2, white blood cell (WBC) count was 2.77, hemoglobin was 9.0, and platelet count was 43. Abdominal imaging showed fatty liver and small volume ascites. The patient was treated with intravenous (IV) fluids, Ativan, Valium per Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol. The patient received treatment with potassium repletion, antibiotics, thiamine, multivitamins, and folic acid. The patient was stated to have no acute events overnight, and no complaints. The patient did not require 'as needed' (PRN) Ativan. Valium was tapered. The patient was on day four of five of antibiotics.
No, the proposed inpatient stay was not medically necessary.
The medical records do not support that the acute inpatient admission was medically necessary. The patient did not require services of such intensity that could have been safely and effectively provided only on an inpatient level of service. The health, safety, and medical condition of the patient would not have been threatened by providing the care given in a lower level of care setting.
An observational level of stay would have been more appropriate for this patient. An observational level of stay would have been a more efficient setting, since the patient did not require any procedural or surgical intervention, did not require to be 'nothing by mouth' for a prolonged duration of time, did not require prolonged treatment with intravenous hydration or intravenous medications, did not have liver failure, did not have gastrointestinal bleeding, did not have acute kidney injury, did not have fevers, did not have an elevated white count, and did not have any complications such as intra-abdominal abscess or a surgical abdomen. The patient did not require 'as needed' (PRN) Ativan since day two.
The patient required intravenous (IV) antibiotics, but the antibiotics could have been administered at a lower level of care.
Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.