Hospital Admission denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for full hospital admission following laparoscopic splenectomy. Fluorodeoxyglucose (FDG)-avid lesions in a positron emission tomography (PET) scan are of the most concern for malignancy, and a splenectomy is indicated for tissue diagnosis. Biopsy of the splenic lesions is usually not recommended due to risk of uncontrolled bleeding and rupture of the spleen, which can be life threatening. Further, post-splenectomy patients have a uniquely severe risk of overwhelming post-splenectomy infection (OPSI), which can occur in the immediate post-operation period, as well as a risk of internal bleeding and thromboembolism.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for hospitalization services.The submitted documentation supports that the services at issue were medically necessary. Atypical symptoms of ischemia can be the presenting signs of an acute coronary syndrome in women (Jones, E., et al.). Diabetes mellitus is a significant cause of death and disability worldwide and is a strong risk factor for acute coronary syndrome (ACS). The excess risk of ACS associated with diabetes is significantly higher in women than in men (Dong, X., et al.). In this case, the patient has a history of diabetes and presented with both typical and atypical symptoms of ischemia. The patient also had an abnormal electrocardiogram (EKG) and was appropriately admitted for a possible acute coronary syndrome.

Where the denial was upheld

A 27-year-old female enrollee requested a hospital stay for treatment of her pregnancy. Findings: The physician reviewer found that the patient presented to the labor and delivery department with an acute history of an abnormal NST. The NST is based on the premise that the heart rate of a fetus that is not acidotic or neurologically depressed will temporarily accelerate with fetal movement. Heart rate reactivity is considered a good indicator of normal fetal autonomic function. Loss of reactivity is most commonly associated with a fetal sleep cycle but may result from any cause of central nervous system depression, including fetal acidemia. The NST results are categorized as reactive or nonreactive.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for hospital admission. Current guidelines for the evaluation and diagnosis of chest pain indicate that “patients with acute chest pain and suspected acute coronary syndrome who have new ischemic changes on electrocardiogram (ECG), troponin-confirmed acute myocardial injury, new-onset [of] left ventricular systolic dysfunction, newly diagnosed moderate-severe ischemia on stress testing, hemodynamic instability, and/or a high clinical decision pathway risk score should be designated as high risk for short-term major adverse cardiovascular events.” In this case, the records submitted for review indicate that the patient had some coronary risk and presented with atypical chest pain.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Hospital Admission, then check the rights and deadlines that apply to your plan.