202306-164550
2023
United Healthcare Plan of New York
Medicaid
Digestive System/ Gastrointestinal
Inpatient Hospital
Medical necessity
Upheld
Case Summary
Diagnosis: Gastroenteritis
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is: Upheld
The patient presented with abdominal pain, nausea, and diarrhea. The patient was afebrile and the vital signs were stable. It was felt that the symptoms were related to food that was spoiled. There were no peritoneal signs. A computed tomography (CT) scan showed cholelithiasis and hepatic steatosis. The patient was diagnosed with gastroenteritis and treated with Cipro and Flagyl. A gastrointestinal (GI) polymerase chain reaction (PCR) panel was negative. The symptoms improved and the patient was able to tolerate a diet.
Medical necessity was determined based on Milliman Care Guidelines (MCG) M-170 for gastroenteritis. Clinical indications for admission include having a suspected severe infection, peritoneal signs, hemodynamic instability, severe vomiting that is not responsive to antiemetics, severe dehydration, severe electrolyte abnormalities, and an inability to maintain oral hydration after observation care. The patient did not have these conditions.
This patient had gastroenteritis. IV hydration, antiemetics, and stool testing could have been done in the Emergency Room (ER) with observation care. Afterwards, the patient could have been discharged on a course of oral antibiotics. The patient did not meet MCG criteria for admission for gastroenteritis.
Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for inpatient hospital services is not substantiated.