Diagnosis: Ascites

Treatment: Inpatient hospital

The insurer denied coverage for inpatient hospital.

The denial is overturned.

This female patient has a history of end stage renal disease (on hemodialysis), hypertension, diabetes mellitus, and normocytic anemia.

The main issue was the abdominal pain that was significant enough that it prevented the patient from presenting for dialysis. The pain was due to ascites and the pelvic mass and management of these conditions was needed. While a paracentesis can be done as an outpatient, due to the patient's myriad medical issues and prior abdominal surgeries and concern about intra-abdominal bleeding in a patient who was already anemic, the procedure had to be performed in the hospital setting. In addition, the patient had significant abdominal pain and there was concern that she will not show up for dialysis. Note that multiple services were involved in this patient's treatment (Nephrology, Medicine Surgery, Gynecology, Interventional Radiology, Gastroenterology, Endocrinology) and the coordination of care between all those services would have been impossible as an outpatient.

Note that the patient's ascitic fluid grew enterococcus faecalis necessitating intravenous (IV) Vancomycin which had to be given very carefully in a patient on dialysis. While the management of a pelvic mass does not usually require hospital admission and dialysis can also be performed as an outpatient, the patient's multiple medical problems required hospitalization to be able to address them.

The health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital is overturned. The medical necessity is substantiated.