Inpatient Hospital Admission denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement for the full inpatient hospital stay. Bronchiolitis is an inflammatory process that affects predominantly small airways. Acute bronchiolitis is a clinical diagnosis given when signs and symptoms include viral upper respiratory prodrome followed by increased respiratory effort, wheezing, and diffuse bilateral crackles, generally affecting infants less than 24 months of age. The most common causative agent is respiratory syncytial virus, but other viruses may also cause bronchiolitis, including adenovirus, rhinovirus, influenza, enterovirus, parainfluenza, and human metapneumovirus. Non-viral causes include mycoplasma, chlamydia, fungi, and mycobacteria.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for hospital inpatient services. California Health and Safety Code § 1317.1, subdivision (a)(1), defines “emergency services and care” as medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility.

Where the denial was upheld

Findings: The physician reviewer found that the patient’s parent has requested reimbursement for inpatient hospital admission. Acute gastroenteritis is a major problem worldwide, representing one of the leading causes of morbidity and mortality in children under five years of age. Most cases are caused by viruses, are self-limited, and require supportive treatment. Oral rehydration therapy is the treatment of choice, particularly where diarrhea is the prominent feature and dehydration is mild to moderate. Intravenous (IV) rehydration is indicated when oral rehydration fails or when output is excessive. Vomiting limits the success of oral rehydration, prompting the use of anti-emetic medications. In this case, the patient, a male infant, presented with acute vomiting, diarrhea, and fever, with poor intake and decreased urine output.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient hospital services. The submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient was hospitalized for treatment of DKA and its sequelae. Her documented medical history was significant for having type 2 diabetes mellitus and headaches. The patient reportedly presented to her primary care provider’s outpatient office. A diagnosis of urinary tract infection was reportedly determined. Laboratory testing was performed, and the patient was subsequently directed to the emergency department. The patient was admitted for inpatient care.

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