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202305-162255

2023

Empire Healthchoice Assurance Inc.

PPO

Digestive System/ Gastrointestinal

Inpatient Hospital

Medical necessity

Upheld

Case Summary

Diagnosis: Abdominal pain
Treatment: Inpatient admission
The health plan denied inpatient admission. The denial is upheld.

The patient is an adult previously-healthy man. He presented to the ED (emergency department) complaining of abdominal pain.

The patient's vital signs in the ED (emergency department) identified a normal temperature, a heart rate of 108/minute, and normal blood pressure. Oxygen saturation was 96%. The WBC (white blood cell) count was 10 K (thousand). Serum electrolytes and renal parameters were normal. Imaging with CT (computed tomography) scan identified findings that suggested enterocolitis and partial small bowel obstruction. He was admitted to the hospital and was treated with antibiotics.

The next day, the patient's diagnosis was considered to be acute enteritis (rather than bowel obstruction). There was no small bowel obstruction per the consulting surgical service. The patient was started on a liquid diet. Vital signs were normal. The patient remained hemodynamically stable throughout the period of monitoring. The WBC (white blood cell) count and the basic metabolic panel were normal. He was considered to be stable for discharge home with continued oral antibiotics.

The health plan rationale for denial of coverage per the letter is that the documentation does not show that the requirements for an inpatient level of care have been met. Per this letter there is no documentation of severe fluid or blood loss or severe infection. The health plan states that this service could have been performed with a lower level of care. This letter references MCG (Milliman Care Guidelines), Gastroenteritis.

Acute inpatient hospitalization was not medically necessary for this patient. The medical records support that this patient could have been reasonably and safely treated with a lower level of care during this time, with subsequent care provided in the outpatient setting.

This patient had abdominal pain and presented to the hospital. He was clinically stable at the time of presentation. The patient was provided IV fluid and antibiotics for enteritis and was able to tolerate oral intake as of the next day. He had consistently normal vital signs following the initial presentation when the heart rate was elevated at 108/minute.

The records support that as of the day after admission, the patient was tolerating diet, oral medications, and demonstrated normal vital signs. Acute inpatient admission was not medically necessary, as the care provided could have been rendered with a lower level of care such as observation. The health plan rationale for denial of inpatient care is appropriate and consistent with medical standards.

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