Inpatient Admission denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for continued inpatient admission. The records indicate that the inpatient admission was medically necessary for the treatment of this patient’s medical condition. The provider noted that the patient’s condition included an underlying gallbladder abscess, which led to septic shock, atrial fibrillation, which was likely triggered by infection, and physical deconditioning as a result of severe illness. The patient was found to have symptomatic bradycardia, which can be a life-threatening condition. In addition, the patient continued to report a fever, which can be a sign of persistent infection.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for an inpatient admission. The risk of compartment syndrome is a known and devastating complication of trauma. As noted in the medical literature, “acute complications of ankle fractures, such as injuries to peripheral nerves or vascular structures, open fractures, and compartment syndrome, are readily identified in most cases and require immediate surgical consultation”.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement for inpatient care services. Many pediatric patients experience an episode or recurrent episodes of wheezing in the first six years of life, often linked to a viral respiratory infection. The records indicate that this pediatric patient was recently enrolled in daycare and diagnosed with viral bronchiolitis several weeks prior to presenting to the emergency department. On that date, the patient’s symptoms included cough, congestion, fever, poor appetite, and new onset wheezing with increased difficulty breathing. The patient was evaluated by his primary care provider the previous day, started on bronchodilator treatment, and given a dose of systemic corticosteroid. However, the patient continued with increased work of breathing prompting evaluation in the emergency department.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for continued inpatient treatment.Cellulitis is an infection of the deep dermis and subcutaneous tissue, presenting with expanding erythema, warmth, tenderness, and swelling. The diagnosis of cellulitis is based primarily on history and physical examination. The majority of cases of cellulitis are nonculturable and therefore the causative bacteria are unknown (Raff, A., and Kroshinsky, D.). Cellulitis is a frequent cause of hospital admission of adult patients (Collazos, J., et al.). In this case, the submitted documentation does not support that the patient’s request for continued inpatient treatment is medically necessary.

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 Inpatient Admission, then check the rights and deadlines that apply to your plan.