Diagnosis: Malignant ascites and continued abdominal pain
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is overturned.

The patient had a history of endometrial carcinoma and presented with abdominal pain. A previous magnetic resonance imaging (MRI) scan showed a liver mass and she had received chemotherapy and radiation. There was a recent course of treatment with antibiotics for diverticulitis. She had persistent diffuse abdominal tenderness, but there was no rebound or guarding. A computed axial tomography (CAT) scan revealed ascites, but did not show acute diverticulitis. There was no leukocytosis. She was able to tolerate a diet and intravenous (IV) pain control was given. She was felt to have peritoneal carcinomatosis with malignant ascites.

Milliman Care Guidelines (MCG) clinical indications for admission for Medical Oncology (MCG GRG: PG-ONC) include having a high-risk infection, gastrointestinal complications such as uncontrollable diarrhea, and malignant ascites which is complicated by respiratory compromise, vomiting, or abdominal pain or discomfort.

This patient had malignant ascites and continued abdominal pain. Tramadol, gabapentin and IV Tylenol were ordered. Since the MCG lists malignant ascites with abdominal pain as an indication for admission, the health care plan did not act reasonably or with sound medical judgment. An inpatient hospital admission was medically necessary.

The insurer's denial of coverage for inpatient hospital admission is overturned. Medical necessity is substantiated.