Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 
The insurer denied Inpatient Admission. 
The denial is upheld. 

The patient is a male child that was transported to the emergency department (ED) via Emergency Medical Services (EMS) with worsening abdominal pain and constipation. He had been constipated for several weeks, passing stool every few days. He was taken to another ED two days prior for constipation and given a fleet enema with some symptom relief. On the day of presentation, he was irritable and holding his abdomen due to pain. His appetite was decreased. He had no fevers or other constitutional symptoms. Examination was significant for alert non-toxic appearance, lying in bed in a position of comfort, with moist mucous membranes, diffuse abdominal tenderness with no guarding or rebound, and non-focal neurologic exam. His vital signs included a temperature at 37.1, heart rate was 95, respiratory rate was 21, and blood pressure was 98/70. There was concern for possible intussusception, appendicitis, pancreatitis, and gastroenteritis.
Abdominal x-ray revealed moderate retained stool in the colon consistent with constipation, with non-obstructive bowel gas pattern. He was admitted for further evaluation of abdominal pain and treatment of dehydration.
Upon admission, there was palpable stool noted on the left side of the abdomen. Admission orders included intravenous (IV) fluids, regular diet for age, famotidine for gut protection, Tylenol as needed for pain, daily Miralax, serial abdominal exams, consideration for fleet enema, and follow-up additional labs. He was given the enema productive of a large volume of stool. 
At issue is the medical necessity of the Inpatient Admission.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Inpatient Admission was not medically necessary for this patient.
Abdominal pain is a frequent presenting complaint to both the clinic and the ED in the pediatric population, representing almost 10% of visits to the primary care office. A detailed history is essential in determining the etiology of pain, including associated symptoms, intensity, location, and previous episodes. Examination can be guided by presenting complaints. Guarding, rebound pain, and absent bowel sounds may be suggestive of need for surgical intervention. Across all ages, the differential includes appendicitis, bowel obstruction, constipation, gallbladder disease, gastroenteritis, mesenteric adenitis, pancreatitis, trauma, urinary tract infection, and upper respiratory infection. Additional causes include dietary indiscretion, trauma including child abuse, sickle cell crisis, and hemolytic uremic syndrome. For girls, menstrual-related conditions, pregnancy, pelvic inflammatory disease, and ovarian torsion should be considered. Abdominal migraine, functional abdominal pain, and mononucleosis may occur. Finally, intussusception, malrotation, Meckel diverticulum, and volvulus may cause abdominal pain. All factors must be taken into consideration when determining course of action.
Constipation is not uncommon in childhood, and at times may be severe. It is typically functional but may indicate presence of an underlying disease process. This young child presented with longstanding constipation with progressively worsening abdominal pain. While in the ED, a number of maladies were excluded, including some of the more serious conditions. Plain x-rays revealed persistent constipation despite use of an enema two days prior. While it was not unreasonable to monitor this child with serial abdominal exams and provide additional measures to relieve his constipation, he was overall hemodynamically stable with no evidence of infection or obstruction, no serious electrolyte abnormalities, and pain was manageable with Tylenol.
Therefore, the requested health service/treatment of Inpatient Admission was not medically necessary.