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202307-165029

2023

Healthfirst, Inc.

Medicaid

Central Nervous System/ Neuromuscular Disorder

Inpatient Hospital

Medical necessity

Overturned

Case Summary

Diagnosis: Back Pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

The patient is an adult female with multiple medical problems who presented to the emergency department with right sided pain. Labs showed elevated white count. The patient had bladder retention. During workup, the patient left against medical advice (AMA).

This was medically necessary.

The patient has multiple concerning findings including the unexplained pain and bladder incontinence which necessitated additional imaging and work-up with consultations such as neurosurgery and neurology. These were all performed within the dates in question and the need for acute inpatient hospitalization is met due to the advanced consultation, imaging and pain control required for this patient. This could not be performed at a lower level of care.

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